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Promoting the Health of Healthcare Employees
Provisions in the Affordable Care Act (ACA) encourage hospitals to work with their communities to improve population health. Like so many things, these efforts can and should begin at home—in this case, the hospital itself. Health and wellness programs for healthcare workers need to be emphasized, according to “Health and Wellness Programs for Hospital Employees: Results from a 2015 American Hospital Association Survey.”1
Such efforts allow healthcare workers to lead by example.
“To help create a culture of health, hospitals and health systems can provide leadership, and hospital employees can be role models, for health and wellness in their communities,” according to the report. “Developing health and wellness strategies and programs at hospitals will help establish an environment that provides the support, resources, and incentives for hospital employees to serve as such role models.”
Developing health and wellness programs can also help hospitals achieve the public health goals of the Healthy People 2020 initiative from the Office of Disease Prevention and Health Promotion.
To find out how hospitals are doing in this work, the 26-question survey was done in 2010 and again in 2015 and sent to approximately 6,000 hospitals in the United States. Response rate was 15% in 2010 and 18% in 2015. Some of the findings include:
- About the same number of hospitals have a health and wellness program or other initiative(s) for employees (86% in 2010 and 87% in 2015); however, the types of health and wellness programs and benefits that hospitals offer to their employees increased.
- The number of hospitals with 70% to 90% or more of employees participating in health and wellness programs increased from 19% in 2010 to 31% in 2015.
- The number of hospitals offering health and wellness programs to people in the community increased from 19% in 2010 to 66% in 2015.
- The number of hospitals offering incentives for participating in health and wellness programs increased as did the value of incentives, with more hospitals giving $500 or more to employees (7% in 2010 and 29% in 2015).
Reference
- Health Research & Educational Trust. Health and wellness programs for hospital employees: results from a 2015 American Hospital Association survey. Hospitals in Pursuit of Excellence website.
Provisions in the Affordable Care Act (ACA) encourage hospitals to work with their communities to improve population health. Like so many things, these efforts can and should begin at home—in this case, the hospital itself. Health and wellness programs for healthcare workers need to be emphasized, according to “Health and Wellness Programs for Hospital Employees: Results from a 2015 American Hospital Association Survey.”1
Such efforts allow healthcare workers to lead by example.
“To help create a culture of health, hospitals and health systems can provide leadership, and hospital employees can be role models, for health and wellness in their communities,” according to the report. “Developing health and wellness strategies and programs at hospitals will help establish an environment that provides the support, resources, and incentives for hospital employees to serve as such role models.”
Developing health and wellness programs can also help hospitals achieve the public health goals of the Healthy People 2020 initiative from the Office of Disease Prevention and Health Promotion.
To find out how hospitals are doing in this work, the 26-question survey was done in 2010 and again in 2015 and sent to approximately 6,000 hospitals in the United States. Response rate was 15% in 2010 and 18% in 2015. Some of the findings include:
- About the same number of hospitals have a health and wellness program or other initiative(s) for employees (86% in 2010 and 87% in 2015); however, the types of health and wellness programs and benefits that hospitals offer to their employees increased.
- The number of hospitals with 70% to 90% or more of employees participating in health and wellness programs increased from 19% in 2010 to 31% in 2015.
- The number of hospitals offering health and wellness programs to people in the community increased from 19% in 2010 to 66% in 2015.
- The number of hospitals offering incentives for participating in health and wellness programs increased as did the value of incentives, with more hospitals giving $500 or more to employees (7% in 2010 and 29% in 2015).
Reference
- Health Research & Educational Trust. Health and wellness programs for hospital employees: results from a 2015 American Hospital Association survey. Hospitals in Pursuit of Excellence website.
Provisions in the Affordable Care Act (ACA) encourage hospitals to work with their communities to improve population health. Like so many things, these efforts can and should begin at home—in this case, the hospital itself. Health and wellness programs for healthcare workers need to be emphasized, according to “Health and Wellness Programs for Hospital Employees: Results from a 2015 American Hospital Association Survey.”1
Such efforts allow healthcare workers to lead by example.
“To help create a culture of health, hospitals and health systems can provide leadership, and hospital employees can be role models, for health and wellness in their communities,” according to the report. “Developing health and wellness strategies and programs at hospitals will help establish an environment that provides the support, resources, and incentives for hospital employees to serve as such role models.”
Developing health and wellness programs can also help hospitals achieve the public health goals of the Healthy People 2020 initiative from the Office of Disease Prevention and Health Promotion.
To find out how hospitals are doing in this work, the 26-question survey was done in 2010 and again in 2015 and sent to approximately 6,000 hospitals in the United States. Response rate was 15% in 2010 and 18% in 2015. Some of the findings include:
- About the same number of hospitals have a health and wellness program or other initiative(s) for employees (86% in 2010 and 87% in 2015); however, the types of health and wellness programs and benefits that hospitals offer to their employees increased.
- The number of hospitals with 70% to 90% or more of employees participating in health and wellness programs increased from 19% in 2010 to 31% in 2015.
- The number of hospitals offering health and wellness programs to people in the community increased from 19% in 2010 to 66% in 2015.
- The number of hospitals offering incentives for participating in health and wellness programs increased as did the value of incentives, with more hospitals giving $500 or more to employees (7% in 2010 and 29% in 2015).
Reference
- Health Research & Educational Trust. Health and wellness programs for hospital employees: results from a 2015 American Hospital Association survey. Hospitals in Pursuit of Excellence website.
Republicans Envision Their Healthcare Plan for the Future
On November 8, 2016, the fate of the Affordable Care Act (ACA) was all but sealed.
In a sweep of the legislative branch, Republicans maintained majorities in the House and Senate, and Donald Trump became the 45th president, running on the popular Republican refrain to “repeal and replace Obamacare.”
“Now, the real onus is going to be on them if they do move to repeal it in its entirety,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “It’s going to be a real burden to replace it with something meaningful and not something that’s recycled from six or eight years ago when the conversation first started.”
In the days following the election, President-elect Trump appeared to be backing off his campaign promises to repeal President Barack Obama’s landmark health reform law, acknowledging that at least some of its provisions should remain intact, including maintaining the ban on insurance companies denying coverage based on preexisting conditions and allowing dependent children to remain on their parents’ health insurance until age 26.
These ideas are also part of House Majority Leader Paul Ryan’s healthcare plan, called A Better Way. However, at least on the campaign trail, Trump and GOP leaders like Rep. Ryan did not see eye-to-eye on all aspects of health reform, including how to deal with Medicare and on issues of pharmaceutical regulation, leaving uncertainty over which platforms will be adopted.
What Comes Next?
“There is a lot of rhetoric out there and a lot of promises to replace the Affordable Care Act, which clearly is an important objective for Republicans, but as sort of a consolation, as [health economist] Stuart Altman used to say before the Affordable Care Act was passed, ‘Everybody’s number-one choice is universal health reform the way they want it, and the second is the status quo,’” says Sherry Glied, MA, PhD, health policy expert and dean of New York University’s Robert F. Wagner Graduate School of Public Service.
But the status quo is no longer an option. Passage of the ACA was driven by high healthcare costs in the U.S. and, in part, around access to coverage. Healthcare spending slowed after passage of the ACA, and while it cannot be fully attributed to the law, cost remains an issue.
The Congressional Budget Office (CBO) estimates that repeal of the ACA would increase the federal deficit by $137 billion to $353 billion between 2016 and 2025, growing even more after 2025.1 And without a mechanism to cover the 20 million people who have gained coverage through Medicaid expansion and private insurance coverage on state exchanges, scores of people could rejoin the ranks of the uninsured.
A Series of Small Cuts
“Whatever system replaces it, don’t expect in Trump’s first week in office Congress will hand him a bill to repeal and replace Obamacare. They’ve tried to do that a number of times in the past, and what they’ve come up with has been a little lackluster. And that’s being generous,” says Dr. Lenchus, who overall supports President-elect Trump’s economic plans and is optimistic about what they could mean for health reform.
Most likely, the ACA will not be repealed in “one fell swoop,” says Glied, who also served under President Obama in the Department of Health and Human Services from 2010 to 2012 and was a senior economist for health care and labor market policy under Presidents George H.W. Bush and Bill Clinton. Rather, lawmakers are likely faced with having to “demolish it through a series of small cuts.”
What that will look like remains unknown. To fully repeal the ACA, Republicans would need 60 filibuster-proof votes in the Senate. However, Republicans have just 51 seats to the Democrats’ 45 after the GOP lost two seats in the November election.
House Republicans can push through a bill using a legislative maneuver called reconciliation, but it requires a majority vote in both chambers and would be restricted to changes that have an impact on the federal budget. At a minimum, Republicans would need a budget before they could attempt this strategy.
They achieved this in late 2015, drafting a bill (H.R. 3762) that would have eliminated Medicaid expansion and the subsidies that currently help 83% of enrollees on the ACA exchange afford their premiums. President Obama vetoed the bill; President-elect Trump is unlikely to do the same.
However, he and Republican party leaders must first come to agreement over what their version of health reform should look like. In general, Republicans have called for a healthcare system rooted in the free market, with more individual responsibility, less regulation, and more flexibility.
For instance, Rep. Ryan’s planwould restrict insurers from denying patients with preexisting conditions but only if individuals maintain continuous coverage, with a one-time open-enrollment opportunity.
Campaign Promises Versus President-Elect Promises
While campaigning, President-elect Trump proposed a seven-point plan that included lifting restrictions on tax-free health savings accounts, providing tax deductions for health insurance premiums, allowing the sale of health insurance across state lines, requiring physicians and hospitals to be transparent about pricing, and eliminating the individual mandate to purchase health insurance. He also proposed converting Medicaid into block grants to states and vowed not to change Medicare.
As president-elect, he has pledged, with few details, to challenge abortion access, further research and development, provide “flexibility” to Medicaid, “modernize” Medicare, and reestablish high-risk pools for sick patients with traditionally high premiums. 1 The ACA does not currently allow insurers to charge sick patients higher rates than healthy ones.
While block grants are one option for attempting to control costs in Medicaid by providing states a fixed sum to administer the entitlement program, Rep. Ryan’s plan calls for another option: per-capita limits on enrollees on Medicaid. He has not detailed what those limits would be. What will happen in states that expanded Medicaid through the ACA relative to those that did not is also unknown.
“Frankly, I think that what this election showed is a complete disdain for the general establishment,” says Dr. Lenchus. “If they do give money to state legislatures, I don’t know if I trust them any more to manage that money than the feds, where they could be robbing that block grant for general revenue.”
While President-elect Trump has not yet provided more information about his plans for Medicare, Republicans in the past, including Rep. Ryan, have proposed offering premium support to beneficiaries (sometimes called a voucher or defined contribution), a fixed sum given to Medicare participants to use toward premiums under traditional Medicare or Medicare Advantage plans.
While this could reduce beneficiaries’ out-of-pocket costs, according to the CBO, spending could also increase and beneficiaries may pay variable out-of-pocket costs. Direct spending, meanwhile, would increase by $879 billion over the next decade if all the ACA and its changes to Medicare are eliminated, hastening depletion of the Medicare trust fund.2
“Frankly, I would not be opposed to seeing a sort of sliding scale for Medicare,” says Dr. Lenchus. “If you’re Warren Buffet taking $150 a month for Medicare, do you need to do that? That $150 spread to three other people who are barely making ends meet could make the difference for them taking a lifesaving medication that month.”
Day-to-Day Medicine
What should and will likely be maintained, both Glied and Dr. Lenchus say, are changes to the delivery of and payment models for healthcare. Medicine has been moving toward higher-quality care and away from fee-for-service for years, and “everybody would agree that’s probably not the correct incentive in medicine,” Dr. Lenchus adds.
With a shift toward more state-level responsibility, Glied says the GOP may also encourage states to innovate around healthcare so long as costs are well-managed. Incidentally, under the ACA, 2017 marks the start of Section 1332 waivers, which provide structure for states to develop their own approaches to healthcare.
However, “changes in the practice of medicine are not going to come out of government,” Glied says. “They’re going to come out of improvements in health IT technology, through changes in the use of midlevel professionals who eventually slide into practice as new residents come out of training.”
Though the election all but guaranteed continued uncertainty moving forward, Dr. Lenchus does not believe it will mean much change in his day-to-day practice of medicine. His safety-net hospital, however, may see an uptick in uncompensated care once more while also trying to survive with cuts to reimbursement made through the ACA.
““I don’t think anyone’s getting the hospitals back that money,” Glied says.
The experts say Congress has its work cut out, particularly as it shapes the future of healthcare in the U.S. based on conservative principles while also taking into account the potential number of newly uninsured patients upon repeal of the ACA.
“The problem is people don’t have coverage because they don’t have money. … Healthcare is expensive, and people are poor,” says Glied. “There is a lots of space to move left in healthcare. It’s hard to see where it can move right.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- President Elect Donald J. Trump. https://www.greatagain.gov/policy/healthcare.html
Accessed November 22, 2016
- Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Accessed November 15, 2016.
On November 8, 2016, the fate of the Affordable Care Act (ACA) was all but sealed.
In a sweep of the legislative branch, Republicans maintained majorities in the House and Senate, and Donald Trump became the 45th president, running on the popular Republican refrain to “repeal and replace Obamacare.”
“Now, the real onus is going to be on them if they do move to repeal it in its entirety,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “It’s going to be a real burden to replace it with something meaningful and not something that’s recycled from six or eight years ago when the conversation first started.”
In the days following the election, President-elect Trump appeared to be backing off his campaign promises to repeal President Barack Obama’s landmark health reform law, acknowledging that at least some of its provisions should remain intact, including maintaining the ban on insurance companies denying coverage based on preexisting conditions and allowing dependent children to remain on their parents’ health insurance until age 26.
These ideas are also part of House Majority Leader Paul Ryan’s healthcare plan, called A Better Way. However, at least on the campaign trail, Trump and GOP leaders like Rep. Ryan did not see eye-to-eye on all aspects of health reform, including how to deal with Medicare and on issues of pharmaceutical regulation, leaving uncertainty over which platforms will be adopted.
What Comes Next?
“There is a lot of rhetoric out there and a lot of promises to replace the Affordable Care Act, which clearly is an important objective for Republicans, but as sort of a consolation, as [health economist] Stuart Altman used to say before the Affordable Care Act was passed, ‘Everybody’s number-one choice is universal health reform the way they want it, and the second is the status quo,’” says Sherry Glied, MA, PhD, health policy expert and dean of New York University’s Robert F. Wagner Graduate School of Public Service.
But the status quo is no longer an option. Passage of the ACA was driven by high healthcare costs in the U.S. and, in part, around access to coverage. Healthcare spending slowed after passage of the ACA, and while it cannot be fully attributed to the law, cost remains an issue.
The Congressional Budget Office (CBO) estimates that repeal of the ACA would increase the federal deficit by $137 billion to $353 billion between 2016 and 2025, growing even more after 2025.1 And without a mechanism to cover the 20 million people who have gained coverage through Medicaid expansion and private insurance coverage on state exchanges, scores of people could rejoin the ranks of the uninsured.
A Series of Small Cuts
“Whatever system replaces it, don’t expect in Trump’s first week in office Congress will hand him a bill to repeal and replace Obamacare. They’ve tried to do that a number of times in the past, and what they’ve come up with has been a little lackluster. And that’s being generous,” says Dr. Lenchus, who overall supports President-elect Trump’s economic plans and is optimistic about what they could mean for health reform.
Most likely, the ACA will not be repealed in “one fell swoop,” says Glied, who also served under President Obama in the Department of Health and Human Services from 2010 to 2012 and was a senior economist for health care and labor market policy under Presidents George H.W. Bush and Bill Clinton. Rather, lawmakers are likely faced with having to “demolish it through a series of small cuts.”
What that will look like remains unknown. To fully repeal the ACA, Republicans would need 60 filibuster-proof votes in the Senate. However, Republicans have just 51 seats to the Democrats’ 45 after the GOP lost two seats in the November election.
House Republicans can push through a bill using a legislative maneuver called reconciliation, but it requires a majority vote in both chambers and would be restricted to changes that have an impact on the federal budget. At a minimum, Republicans would need a budget before they could attempt this strategy.
They achieved this in late 2015, drafting a bill (H.R. 3762) that would have eliminated Medicaid expansion and the subsidies that currently help 83% of enrollees on the ACA exchange afford their premiums. President Obama vetoed the bill; President-elect Trump is unlikely to do the same.
However, he and Republican party leaders must first come to agreement over what their version of health reform should look like. In general, Republicans have called for a healthcare system rooted in the free market, with more individual responsibility, less regulation, and more flexibility.
For instance, Rep. Ryan’s planwould restrict insurers from denying patients with preexisting conditions but only if individuals maintain continuous coverage, with a one-time open-enrollment opportunity.
Campaign Promises Versus President-Elect Promises
While campaigning, President-elect Trump proposed a seven-point plan that included lifting restrictions on tax-free health savings accounts, providing tax deductions for health insurance premiums, allowing the sale of health insurance across state lines, requiring physicians and hospitals to be transparent about pricing, and eliminating the individual mandate to purchase health insurance. He also proposed converting Medicaid into block grants to states and vowed not to change Medicare.
As president-elect, he has pledged, with few details, to challenge abortion access, further research and development, provide “flexibility” to Medicaid, “modernize” Medicare, and reestablish high-risk pools for sick patients with traditionally high premiums. 1 The ACA does not currently allow insurers to charge sick patients higher rates than healthy ones.
While block grants are one option for attempting to control costs in Medicaid by providing states a fixed sum to administer the entitlement program, Rep. Ryan’s plan calls for another option: per-capita limits on enrollees on Medicaid. He has not detailed what those limits would be. What will happen in states that expanded Medicaid through the ACA relative to those that did not is also unknown.
“Frankly, I think that what this election showed is a complete disdain for the general establishment,” says Dr. Lenchus. “If they do give money to state legislatures, I don’t know if I trust them any more to manage that money than the feds, where they could be robbing that block grant for general revenue.”
While President-elect Trump has not yet provided more information about his plans for Medicare, Republicans in the past, including Rep. Ryan, have proposed offering premium support to beneficiaries (sometimes called a voucher or defined contribution), a fixed sum given to Medicare participants to use toward premiums under traditional Medicare or Medicare Advantage plans.
While this could reduce beneficiaries’ out-of-pocket costs, according to the CBO, spending could also increase and beneficiaries may pay variable out-of-pocket costs. Direct spending, meanwhile, would increase by $879 billion over the next decade if all the ACA and its changes to Medicare are eliminated, hastening depletion of the Medicare trust fund.2
“Frankly, I would not be opposed to seeing a sort of sliding scale for Medicare,” says Dr. Lenchus. “If you’re Warren Buffet taking $150 a month for Medicare, do you need to do that? That $150 spread to three other people who are barely making ends meet could make the difference for them taking a lifesaving medication that month.”
Day-to-Day Medicine
What should and will likely be maintained, both Glied and Dr. Lenchus say, are changes to the delivery of and payment models for healthcare. Medicine has been moving toward higher-quality care and away from fee-for-service for years, and “everybody would agree that’s probably not the correct incentive in medicine,” Dr. Lenchus adds.
With a shift toward more state-level responsibility, Glied says the GOP may also encourage states to innovate around healthcare so long as costs are well-managed. Incidentally, under the ACA, 2017 marks the start of Section 1332 waivers, which provide structure for states to develop their own approaches to healthcare.
However, “changes in the practice of medicine are not going to come out of government,” Glied says. “They’re going to come out of improvements in health IT technology, through changes in the use of midlevel professionals who eventually slide into practice as new residents come out of training.”
Though the election all but guaranteed continued uncertainty moving forward, Dr. Lenchus does not believe it will mean much change in his day-to-day practice of medicine. His safety-net hospital, however, may see an uptick in uncompensated care once more while also trying to survive with cuts to reimbursement made through the ACA.
““I don’t think anyone’s getting the hospitals back that money,” Glied says.
The experts say Congress has its work cut out, particularly as it shapes the future of healthcare in the U.S. based on conservative principles while also taking into account the potential number of newly uninsured patients upon repeal of the ACA.
“The problem is people don’t have coverage because they don’t have money. … Healthcare is expensive, and people are poor,” says Glied. “There is a lots of space to move left in healthcare. It’s hard to see where it can move right.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- President Elect Donald J. Trump. https://www.greatagain.gov/policy/healthcare.html
Accessed November 22, 2016
- Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Accessed November 15, 2016.
On November 8, 2016, the fate of the Affordable Care Act (ACA) was all but sealed.
In a sweep of the legislative branch, Republicans maintained majorities in the House and Senate, and Donald Trump became the 45th president, running on the popular Republican refrain to “repeal and replace Obamacare.”
“Now, the real onus is going to be on them if they do move to repeal it in its entirety,” says Joshua Lenchus, DO, RPh, FACP, SFHM, a hospitalist at the University of Miami/Jackson Memorial Hospital in Florida and a member of SHM’s Public Policy Committee. “It’s going to be a real burden to replace it with something meaningful and not something that’s recycled from six or eight years ago when the conversation first started.”
In the days following the election, President-elect Trump appeared to be backing off his campaign promises to repeal President Barack Obama’s landmark health reform law, acknowledging that at least some of its provisions should remain intact, including maintaining the ban on insurance companies denying coverage based on preexisting conditions and allowing dependent children to remain on their parents’ health insurance until age 26.
These ideas are also part of House Majority Leader Paul Ryan’s healthcare plan, called A Better Way. However, at least on the campaign trail, Trump and GOP leaders like Rep. Ryan did not see eye-to-eye on all aspects of health reform, including how to deal with Medicare and on issues of pharmaceutical regulation, leaving uncertainty over which platforms will be adopted.
What Comes Next?
“There is a lot of rhetoric out there and a lot of promises to replace the Affordable Care Act, which clearly is an important objective for Republicans, but as sort of a consolation, as [health economist] Stuart Altman used to say before the Affordable Care Act was passed, ‘Everybody’s number-one choice is universal health reform the way they want it, and the second is the status quo,’” says Sherry Glied, MA, PhD, health policy expert and dean of New York University’s Robert F. Wagner Graduate School of Public Service.
But the status quo is no longer an option. Passage of the ACA was driven by high healthcare costs in the U.S. and, in part, around access to coverage. Healthcare spending slowed after passage of the ACA, and while it cannot be fully attributed to the law, cost remains an issue.
The Congressional Budget Office (CBO) estimates that repeal of the ACA would increase the federal deficit by $137 billion to $353 billion between 2016 and 2025, growing even more after 2025.1 And without a mechanism to cover the 20 million people who have gained coverage through Medicaid expansion and private insurance coverage on state exchanges, scores of people could rejoin the ranks of the uninsured.
A Series of Small Cuts
“Whatever system replaces it, don’t expect in Trump’s first week in office Congress will hand him a bill to repeal and replace Obamacare. They’ve tried to do that a number of times in the past, and what they’ve come up with has been a little lackluster. And that’s being generous,” says Dr. Lenchus, who overall supports President-elect Trump’s economic plans and is optimistic about what they could mean for health reform.
Most likely, the ACA will not be repealed in “one fell swoop,” says Glied, who also served under President Obama in the Department of Health and Human Services from 2010 to 2012 and was a senior economist for health care and labor market policy under Presidents George H.W. Bush and Bill Clinton. Rather, lawmakers are likely faced with having to “demolish it through a series of small cuts.”
What that will look like remains unknown. To fully repeal the ACA, Republicans would need 60 filibuster-proof votes in the Senate. However, Republicans have just 51 seats to the Democrats’ 45 after the GOP lost two seats in the November election.
House Republicans can push through a bill using a legislative maneuver called reconciliation, but it requires a majority vote in both chambers and would be restricted to changes that have an impact on the federal budget. At a minimum, Republicans would need a budget before they could attempt this strategy.
They achieved this in late 2015, drafting a bill (H.R. 3762) that would have eliminated Medicaid expansion and the subsidies that currently help 83% of enrollees on the ACA exchange afford their premiums. President Obama vetoed the bill; President-elect Trump is unlikely to do the same.
However, he and Republican party leaders must first come to agreement over what their version of health reform should look like. In general, Republicans have called for a healthcare system rooted in the free market, with more individual responsibility, less regulation, and more flexibility.
For instance, Rep. Ryan’s planwould restrict insurers from denying patients with preexisting conditions but only if individuals maintain continuous coverage, with a one-time open-enrollment opportunity.
Campaign Promises Versus President-Elect Promises
While campaigning, President-elect Trump proposed a seven-point plan that included lifting restrictions on tax-free health savings accounts, providing tax deductions for health insurance premiums, allowing the sale of health insurance across state lines, requiring physicians and hospitals to be transparent about pricing, and eliminating the individual mandate to purchase health insurance. He also proposed converting Medicaid into block grants to states and vowed not to change Medicare.
As president-elect, he has pledged, with few details, to challenge abortion access, further research and development, provide “flexibility” to Medicaid, “modernize” Medicare, and reestablish high-risk pools for sick patients with traditionally high premiums. 1 The ACA does not currently allow insurers to charge sick patients higher rates than healthy ones.
While block grants are one option for attempting to control costs in Medicaid by providing states a fixed sum to administer the entitlement program, Rep. Ryan’s plan calls for another option: per-capita limits on enrollees on Medicaid. He has not detailed what those limits would be. What will happen in states that expanded Medicaid through the ACA relative to those that did not is also unknown.
“Frankly, I think that what this election showed is a complete disdain for the general establishment,” says Dr. Lenchus. “If they do give money to state legislatures, I don’t know if I trust them any more to manage that money than the feds, where they could be robbing that block grant for general revenue.”
While President-elect Trump has not yet provided more information about his plans for Medicare, Republicans in the past, including Rep. Ryan, have proposed offering premium support to beneficiaries (sometimes called a voucher or defined contribution), a fixed sum given to Medicare participants to use toward premiums under traditional Medicare or Medicare Advantage plans.
While this could reduce beneficiaries’ out-of-pocket costs, according to the CBO, spending could also increase and beneficiaries may pay variable out-of-pocket costs. Direct spending, meanwhile, would increase by $879 billion over the next decade if all the ACA and its changes to Medicare are eliminated, hastening depletion of the Medicare trust fund.2
“Frankly, I would not be opposed to seeing a sort of sliding scale for Medicare,” says Dr. Lenchus. “If you’re Warren Buffet taking $150 a month for Medicare, do you need to do that? That $150 spread to three other people who are barely making ends meet could make the difference for them taking a lifesaving medication that month.”
Day-to-Day Medicine
What should and will likely be maintained, both Glied and Dr. Lenchus say, are changes to the delivery of and payment models for healthcare. Medicine has been moving toward higher-quality care and away from fee-for-service for years, and “everybody would agree that’s probably not the correct incentive in medicine,” Dr. Lenchus adds.
With a shift toward more state-level responsibility, Glied says the GOP may also encourage states to innovate around healthcare so long as costs are well-managed. Incidentally, under the ACA, 2017 marks the start of Section 1332 waivers, which provide structure for states to develop their own approaches to healthcare.
However, “changes in the practice of medicine are not going to come out of government,” Glied says. “They’re going to come out of improvements in health IT technology, through changes in the use of midlevel professionals who eventually slide into practice as new residents come out of training.”
Though the election all but guaranteed continued uncertainty moving forward, Dr. Lenchus does not believe it will mean much change in his day-to-day practice of medicine. His safety-net hospital, however, may see an uptick in uncompensated care once more while also trying to survive with cuts to reimbursement made through the ACA.
““I don’t think anyone’s getting the hospitals back that money,” Glied says.
The experts say Congress has its work cut out, particularly as it shapes the future of healthcare in the U.S. based on conservative principles while also taking into account the potential number of newly uninsured patients upon repeal of the ACA.
“The problem is people don’t have coverage because they don’t have money. … Healthcare is expensive, and people are poor,” says Glied. “There is a lots of space to move left in healthcare. It’s hard to see where it can move right.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
- President Elect Donald J. Trump. https://www.greatagain.gov/policy/healthcare.html
Accessed November 22, 2016
- Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Accessed November 15, 2016.
Trump administration to focus on ACA reform, tort reform
Look for three things from the Trump administration: significant changes to the Affordable Care Act, few changes to MACRA’s Quality Payment Program, and a conservative swing in the courts.
Republicans have had their sights on the Affordable Care Act since its passage in 2010; with majorities in both the House and the Senate, the question is not if, but when President Obama’s signature piece of legislation will be dismantled.
President-elect Donald Trump ran on the promise of ACA repeal. Health policy priorities on his transition website focus on greater use of health savings accounts, the ability to purchase insurance across state lines, and the reestablishment of high-risk pools.
Health policy experts differ in how they see ACA reform coming about, with some predicting a quick repeal coupled with an immediate legislative replacement, while others envision repeal with more time to craft replacement legislation. Reform also could come as a series of smaller bills rather than one comprehensive package.
Using budget reconciliation would not allow for full ACA repeal since only provisions that involve revenue generation or spending could be altered. However, since budget reconciliation bills cannot be filibustered, only a simple majority is needed for Senate passage. With their razor-thin majority – 51 seats – Republicans will need some support from outside of their own party.
“Twenty-some Democrats, many in very-deep ‘red states’ including North Dakota, are up for reelection in 2018,” Ms. Turner said. “They saw what happened to the candidates who supported Obamacare in 2016 – many of them went down. It happened with Evan Bayh in Indiana, who was running again to reclaim the Senate seat he left in 2010. And the Republican candidate [Todd Young] reminded the voters over and over that Evan Bayh voted for Obamacare. Same thing happened in Wisconsin with [Republican] Sen. Ron Johnson being challenged by Russ Feingold, who also was in the Senate when Obamacare passed. Feingold went down to defeat again. I think the lot of Democratic senators are going to be looking at what happened to those people and think ‘Maybe I better participate in coming up with a more sensible solution.’ ”
More importantly, the GOP may be looking for bipartisan support, especially since the ACA passed on a strict party-line vote. To that end, it could make more sense to delay reform efforts until a broader coalition can be formed and simultaneous repeal/replace package could be brought to both the House and the Senate floors.
In the new Congress, Senate Republicans might face some of the same obstructionist tactics they used during the Obama administration, which could complicate efforts to get bipartisan support.
“When you have people like Sen. [Bernie] Sanders (I-Vt.) and Sen. [Elizabeth] Warren (D-Mass.) saying they are going to adapt a scorched earth approach going forward, they and their followers don’t have any intention of doing anything that would in any way appear to cooperate with the Republicans,” Dr. Wilensky said. “Of course, there are other Democrats, especially some of the ones who will be up in 2018, who might not be quite so adamant.”
“Repeal without a clear idea of what the replacement would be would really throw that market into chaos, where right now we are at a place where the markets are relatively stable,” Dr. Collins said in an interview.“The best way to think about the ACA, and particularly on the marketplaces and what repeal means, is this image of the three-legged stool. The individual market is the seat and the legs include consumer protections, particularly guaranteed issue; the individual requirement to have insurance; and the subsidies to make that coverage affordable – Medicaid expansion is part of that as well. If you start to remove any one of those legs, the market becomes extremely unstable.”
Repealing the individual mandate is problematic as it goes hand in hand with the ban on coverage denial because of preexisting conditions, something President-elect Trump has signaled he is looking to maintain, Ms. Turner said, adding that free market solutions with appropriate incentives could be a different way to encourage healthy people to get coverage to help generate premium revenue to cover patients with preexisting conditions.
While the ACA will be in the crosshairs, experts expect MACRA to remain more or less intact, maybe with some minor tweaks, at least early on.
While the Medicare Access and CHIP Reauthorization Act of 2015 passed with overwhelming support from both parties, “the [implementing regulations] are just a nightmare and I think the Trump administration is going to have to take a look at them,” Ms. Turner said. She added that physicians are weary of the ever-growing federal administrative hassles. “You do not want doctors to leave private practice in droves, and they are looking at this cost of compliance.”
“I think that [MACRA] is just way too much of an in-the-weeds policy thing for the Trump administration to have addressed yet,” Ms. Turner continued. “But this certainly is going to have to be on the agenda because they are going to hear from a lot of doctors that this is not acceptable.”
Mr. Trump also has called for Medicaid reform, with block grants to the states.
“Everyone keeps talking about a block grant, but that is a clumsy way of doing it,” Ms. Turner said, suggesting the program be even more refined to cover people in different baskets, including dual-eligibles, healthy adults that were part of the ACA Medicaid expansion, mothers and infants, and disabled individuals. “A capitated allotment [allows the government to provide more support to] the people who need it.”
Dr. Wilensky suggested that the Trump administration could revisit the 1332 waiver process, another provision of the ACA.
“The current administration has taken a very-rigid view on that you have to keep savings from Medicaid and the ACA separate and any changes have to be budget neutral to each, which is an extremely rigid set of requirements,” she said. Instead “Medicaid and ACA savings could count together and it just needs to be budget neutral over a 3- or 5-year period. That would then allow states to come in and request a lot of flexibility that the current administration hasn’t been inclined to give them.”
Likewise, the Children’s Health Insurance Plan (CHIP) is up for reauthorization. While the program remains relatively popular, it could be due for some reforms as well. Dr. Wilensky said it might be time for the program to go away, though doing that would face resistance from congressional Democrats.
Likewise, Ms. Turner suggested it could be time to fold CHIP into another program like Medicaid.
“Does it really make sense for a mother who is overwhelmed, maybe even with two jobs, to have her kids on a different health insurance program than she’s on?” Ms. Turner said. “It just adds to the burden and the paperwork. Would it make more sense to blend some of these programs together, making sure the people get the health coverage they need, but without all these artificial silos that really make it much more difficult for the user at the other end. I think they are going to take a look at that.”
Whether the ACA is amended or repealed may affect some – but not all – of the ACA-related cases lingering in the courts.
Zubik v. Burwell for instance, may become irrelevant if President-elect Trump eliminates the ACA’s birth control mandate or its accommodation clause. Zubik centers on an exception to the birth control mandate for organizations that oppose coverage for contraceptives but are not exempted entities, such as churches. The plaintiffs argue that the government’s opt-out process makes them complicit in offering contraception coverage indirectly.
The Trump administration could choose to broaden the mandate’s exemption to include the religious organizations, thus satisfying the plaintiffs, said Timothy S. Jost, a health law professor at Washington and Lee University in Lexington, Va., who added that the case would become moot if the ACA is repealed wholesale.
“Millions of women [currently] get access to birth control without cost sharing through the Affordable Care Act,” he said in an interview. “That’s an issue [the new administration] is going to have to confront.”
In March, U.S. Supreme Court justices requested that both sides provide new briefs that outlined how contraception could be provided without requiring notice on the part of the suing employers. Then, in light of the briefs, the high court vacated the lower court rulings related to Zubik and remanded the case to the four appeals courts that had originally ruled on the issue.
If the case makes its way back to the Supreme Court, the ultimate ruling will largely depend on the makeup of the court at the time, said Eric D. Fader, a New York–based health law attorney.
“As long as we have a 4-4 Supreme Court, everything is up in the air,” Mr. Fader said in an interview. “As soon as that ninth slot is filled, I think we’re going to see some decisions that are going to be in line with traditional Republican conservative positions.”
However, a set of ACA-related cases that involve payments to insurers will continue litigating, regardless of actions by the new administration, analysts said. A half-dozen health insurers have sued the Health & Human Services department over alleged underpayments under the ACA’s risk corridor program.
“Even if you do away with the ACA, these cases all pertain to conduct that has already occurred, so they’re not going to be automatically moot,” Mr. Fader said in an interview. “They may struggle along for a while.”
The cases stem from the ACA’s risk corridor program, which requires HHS to collect funds from excessively profitable insurers that offer qualified health plans under the exchanges, while paying out funds to QHP insurers that have excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
The plaintiffs allege they’ve been shortchanged and that the government must reimburse them full payments for 2014. The Department of Justice (DOJ) argues the cases are premature because the full amount owed under the program is not due until 2016, after the program runs its course.
The Trump administration may surrender another ACA-linked challenge that questions billions in payments made to insurers, Mr. Jost said in an interview. In House v. Burwell, the House of Representatives accuses HHS of wrongly spending billions to repay insurers for health insurance provided to certain low-income patients under the ACA. The House claims HHS is illegally spending monies that Congress never appropriated. HHS argues that other statutory provisions of the ACA authorize expenditures for cost-sharing reimbursements. In May, the U.S. District Court for the District of Columbia decided in favor of the House, ruling that Congress never appropriated money for the payments and that no public money can be spent without an appropriation.
There is speculation that the Trump administration may not pursue an appeal, Mr. Jost said. “I think they better think long and hard about that because I don’t know why any president would want court precedent saying one house of Congress can sue the president whenever it disagrees,” he said. “If the Trump administration would give in on the lawsuit or the House would win … there would be some very large losses and some very large premium increases next year. There could be some very significant disruption of insurance markets.”
Again, if the ACA is repealed, the case may become irrelevant, Mr. Fader said. “If you get rid of the ACA and eliminate the cost sharing structure, than House v. Burwell is going to just be moot.”
“We have seen a substantial uptick in antitrust enforcement activity in health care over the last several years,” he said in an interview. “The Trump administration has said that one of its themes is reducing the regulatory burden on businesses. People will be watching to see if that means an attempt to back off of some of the more-aggressive antitrust enforcement activities in health care and other industries.”
The Obama administration is currently fighting to block two mega-mergers among four of the largest health insurers in the nation. The DOJ filed legal challenges earlier this year seeking to ban Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana. The lawsuits allege the mergers – valued at $54 billion and $37 billion respectively – would negatively affect doctors, patients, and employers by limiting price competition, reducing benefits, and lowering quality of care. A majority of physician associations and patient groups oppose the mergers. But experts said the new administration could drop the challenges.
Similarly, the Trump administration could be more lax in its enforcement of the Stark Law. “You could certainly say if the administration is committed to reducing regulatory burden, one thing the administration might push forward is reducing some of the enforcement with respect to technical violations of Stark,” Mr. Horton said, noting that the Senate recently questioned if the government is going too far in regulating physician relationships under Stark. “If your theme is ‘Let’s cut back on regulation,’ that would be an area that you would think the administration would look at.”
Meanwhile, stronger medical malpractice reforms could be on the horizon in light of a Republican-controlled Congress. Tort reform advocates have a good chance at passing federal medical liability reforms that were left out of the ACA’s passage in 2010, said Dennis A. Cardoza, public affairs director and cochair of the federal public affairs practice at a national health law firm.
Earlier versions of the ACA included amendments that mandated lawsuits go through a state or federal alternative dispute resolution system prior to being filed in court. Another provision that failed would have provided federal grants to states that created special health courts for medical malpractice claims. The amendment would have allowed states to create expert panels, administrative health care tribunals, or a combination of the two.
“There’s much stronger support for tort reform among the Republicans in Congress,” Mr. Cardoza said in an interview. “There’s a shot [now]. If the reforms don’t go too far where they would penalize injured patients, I think they could get additional support and be well received by the Congress.”
Tougher abortion restrictions are likely under the Trump administration, experts said. President-elect Trump has said he is committed to nominating a ninth Supreme Court justice who opposes Roe v. Wade.
Vice President-elect Mike Pence, who is considered a strong voice for the religious right, will likely influence who Mr. Trump nominates for the high court, said Rep-elect Raskin, who added that if ever there was time that abortion rights are in jeopardy, it’s now.
“This really puts the Republicans to the test,” he said in an interview. “For decades now, they have been calling for the overruling of Roe v. Wade. The religious right will never forgive them if it doesn’t happen now. [Republicans] control the House, the Senate, and the White House. They have it within their reach to create a five-justice majority on the court.”
[email protected]
[email protected]
On Twitter @legal_med
Look for three things from the Trump administration: significant changes to the Affordable Care Act, few changes to MACRA’s Quality Payment Program, and a conservative swing in the courts.
Republicans have had their sights on the Affordable Care Act since its passage in 2010; with majorities in both the House and the Senate, the question is not if, but when President Obama’s signature piece of legislation will be dismantled.
President-elect Donald Trump ran on the promise of ACA repeal. Health policy priorities on his transition website focus on greater use of health savings accounts, the ability to purchase insurance across state lines, and the reestablishment of high-risk pools.
Health policy experts differ in how they see ACA reform coming about, with some predicting a quick repeal coupled with an immediate legislative replacement, while others envision repeal with more time to craft replacement legislation. Reform also could come as a series of smaller bills rather than one comprehensive package.
Using budget reconciliation would not allow for full ACA repeal since only provisions that involve revenue generation or spending could be altered. However, since budget reconciliation bills cannot be filibustered, only a simple majority is needed for Senate passage. With their razor-thin majority – 51 seats – Republicans will need some support from outside of their own party.
“Twenty-some Democrats, many in very-deep ‘red states’ including North Dakota, are up for reelection in 2018,” Ms. Turner said. “They saw what happened to the candidates who supported Obamacare in 2016 – many of them went down. It happened with Evan Bayh in Indiana, who was running again to reclaim the Senate seat he left in 2010. And the Republican candidate [Todd Young] reminded the voters over and over that Evan Bayh voted for Obamacare. Same thing happened in Wisconsin with [Republican] Sen. Ron Johnson being challenged by Russ Feingold, who also was in the Senate when Obamacare passed. Feingold went down to defeat again. I think the lot of Democratic senators are going to be looking at what happened to those people and think ‘Maybe I better participate in coming up with a more sensible solution.’ ”
More importantly, the GOP may be looking for bipartisan support, especially since the ACA passed on a strict party-line vote. To that end, it could make more sense to delay reform efforts until a broader coalition can be formed and simultaneous repeal/replace package could be brought to both the House and the Senate floors.
In the new Congress, Senate Republicans might face some of the same obstructionist tactics they used during the Obama administration, which could complicate efforts to get bipartisan support.
“When you have people like Sen. [Bernie] Sanders (I-Vt.) and Sen. [Elizabeth] Warren (D-Mass.) saying they are going to adapt a scorched earth approach going forward, they and their followers don’t have any intention of doing anything that would in any way appear to cooperate with the Republicans,” Dr. Wilensky said. “Of course, there are other Democrats, especially some of the ones who will be up in 2018, who might not be quite so adamant.”
“Repeal without a clear idea of what the replacement would be would really throw that market into chaos, where right now we are at a place where the markets are relatively stable,” Dr. Collins said in an interview.“The best way to think about the ACA, and particularly on the marketplaces and what repeal means, is this image of the three-legged stool. The individual market is the seat and the legs include consumer protections, particularly guaranteed issue; the individual requirement to have insurance; and the subsidies to make that coverage affordable – Medicaid expansion is part of that as well. If you start to remove any one of those legs, the market becomes extremely unstable.”
Repealing the individual mandate is problematic as it goes hand in hand with the ban on coverage denial because of preexisting conditions, something President-elect Trump has signaled he is looking to maintain, Ms. Turner said, adding that free market solutions with appropriate incentives could be a different way to encourage healthy people to get coverage to help generate premium revenue to cover patients with preexisting conditions.
While the ACA will be in the crosshairs, experts expect MACRA to remain more or less intact, maybe with some minor tweaks, at least early on.
While the Medicare Access and CHIP Reauthorization Act of 2015 passed with overwhelming support from both parties, “the [implementing regulations] are just a nightmare and I think the Trump administration is going to have to take a look at them,” Ms. Turner said. She added that physicians are weary of the ever-growing federal administrative hassles. “You do not want doctors to leave private practice in droves, and they are looking at this cost of compliance.”
“I think that [MACRA] is just way too much of an in-the-weeds policy thing for the Trump administration to have addressed yet,” Ms. Turner continued. “But this certainly is going to have to be on the agenda because they are going to hear from a lot of doctors that this is not acceptable.”
Mr. Trump also has called for Medicaid reform, with block grants to the states.
“Everyone keeps talking about a block grant, but that is a clumsy way of doing it,” Ms. Turner said, suggesting the program be even more refined to cover people in different baskets, including dual-eligibles, healthy adults that were part of the ACA Medicaid expansion, mothers and infants, and disabled individuals. “A capitated allotment [allows the government to provide more support to] the people who need it.”
Dr. Wilensky suggested that the Trump administration could revisit the 1332 waiver process, another provision of the ACA.
“The current administration has taken a very-rigid view on that you have to keep savings from Medicaid and the ACA separate and any changes have to be budget neutral to each, which is an extremely rigid set of requirements,” she said. Instead “Medicaid and ACA savings could count together and it just needs to be budget neutral over a 3- or 5-year period. That would then allow states to come in and request a lot of flexibility that the current administration hasn’t been inclined to give them.”
Likewise, the Children’s Health Insurance Plan (CHIP) is up for reauthorization. While the program remains relatively popular, it could be due for some reforms as well. Dr. Wilensky said it might be time for the program to go away, though doing that would face resistance from congressional Democrats.
Likewise, Ms. Turner suggested it could be time to fold CHIP into another program like Medicaid.
“Does it really make sense for a mother who is overwhelmed, maybe even with two jobs, to have her kids on a different health insurance program than she’s on?” Ms. Turner said. “It just adds to the burden and the paperwork. Would it make more sense to blend some of these programs together, making sure the people get the health coverage they need, but without all these artificial silos that really make it much more difficult for the user at the other end. I think they are going to take a look at that.”
Whether the ACA is amended or repealed may affect some – but not all – of the ACA-related cases lingering in the courts.
Zubik v. Burwell for instance, may become irrelevant if President-elect Trump eliminates the ACA’s birth control mandate or its accommodation clause. Zubik centers on an exception to the birth control mandate for organizations that oppose coverage for contraceptives but are not exempted entities, such as churches. The plaintiffs argue that the government’s opt-out process makes them complicit in offering contraception coverage indirectly.
The Trump administration could choose to broaden the mandate’s exemption to include the religious organizations, thus satisfying the plaintiffs, said Timothy S. Jost, a health law professor at Washington and Lee University in Lexington, Va., who added that the case would become moot if the ACA is repealed wholesale.
“Millions of women [currently] get access to birth control without cost sharing through the Affordable Care Act,” he said in an interview. “That’s an issue [the new administration] is going to have to confront.”
In March, U.S. Supreme Court justices requested that both sides provide new briefs that outlined how contraception could be provided without requiring notice on the part of the suing employers. Then, in light of the briefs, the high court vacated the lower court rulings related to Zubik and remanded the case to the four appeals courts that had originally ruled on the issue.
If the case makes its way back to the Supreme Court, the ultimate ruling will largely depend on the makeup of the court at the time, said Eric D. Fader, a New York–based health law attorney.
“As long as we have a 4-4 Supreme Court, everything is up in the air,” Mr. Fader said in an interview. “As soon as that ninth slot is filled, I think we’re going to see some decisions that are going to be in line with traditional Republican conservative positions.”
However, a set of ACA-related cases that involve payments to insurers will continue litigating, regardless of actions by the new administration, analysts said. A half-dozen health insurers have sued the Health & Human Services department over alleged underpayments under the ACA’s risk corridor program.
“Even if you do away with the ACA, these cases all pertain to conduct that has already occurred, so they’re not going to be automatically moot,” Mr. Fader said in an interview. “They may struggle along for a while.”
The cases stem from the ACA’s risk corridor program, which requires HHS to collect funds from excessively profitable insurers that offer qualified health plans under the exchanges, while paying out funds to QHP insurers that have excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
The plaintiffs allege they’ve been shortchanged and that the government must reimburse them full payments for 2014. The Department of Justice (DOJ) argues the cases are premature because the full amount owed under the program is not due until 2016, after the program runs its course.
The Trump administration may surrender another ACA-linked challenge that questions billions in payments made to insurers, Mr. Jost said in an interview. In House v. Burwell, the House of Representatives accuses HHS of wrongly spending billions to repay insurers for health insurance provided to certain low-income patients under the ACA. The House claims HHS is illegally spending monies that Congress never appropriated. HHS argues that other statutory provisions of the ACA authorize expenditures for cost-sharing reimbursements. In May, the U.S. District Court for the District of Columbia decided in favor of the House, ruling that Congress never appropriated money for the payments and that no public money can be spent without an appropriation.
There is speculation that the Trump administration may not pursue an appeal, Mr. Jost said. “I think they better think long and hard about that because I don’t know why any president would want court precedent saying one house of Congress can sue the president whenever it disagrees,” he said. “If the Trump administration would give in on the lawsuit or the House would win … there would be some very large losses and some very large premium increases next year. There could be some very significant disruption of insurance markets.”
Again, if the ACA is repealed, the case may become irrelevant, Mr. Fader said. “If you get rid of the ACA and eliminate the cost sharing structure, than House v. Burwell is going to just be moot.”
“We have seen a substantial uptick in antitrust enforcement activity in health care over the last several years,” he said in an interview. “The Trump administration has said that one of its themes is reducing the regulatory burden on businesses. People will be watching to see if that means an attempt to back off of some of the more-aggressive antitrust enforcement activities in health care and other industries.”
The Obama administration is currently fighting to block two mega-mergers among four of the largest health insurers in the nation. The DOJ filed legal challenges earlier this year seeking to ban Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana. The lawsuits allege the mergers – valued at $54 billion and $37 billion respectively – would negatively affect doctors, patients, and employers by limiting price competition, reducing benefits, and lowering quality of care. A majority of physician associations and patient groups oppose the mergers. But experts said the new administration could drop the challenges.
Similarly, the Trump administration could be more lax in its enforcement of the Stark Law. “You could certainly say if the administration is committed to reducing regulatory burden, one thing the administration might push forward is reducing some of the enforcement with respect to technical violations of Stark,” Mr. Horton said, noting that the Senate recently questioned if the government is going too far in regulating physician relationships under Stark. “If your theme is ‘Let’s cut back on regulation,’ that would be an area that you would think the administration would look at.”
Meanwhile, stronger medical malpractice reforms could be on the horizon in light of a Republican-controlled Congress. Tort reform advocates have a good chance at passing federal medical liability reforms that were left out of the ACA’s passage in 2010, said Dennis A. Cardoza, public affairs director and cochair of the federal public affairs practice at a national health law firm.
Earlier versions of the ACA included amendments that mandated lawsuits go through a state or federal alternative dispute resolution system prior to being filed in court. Another provision that failed would have provided federal grants to states that created special health courts for medical malpractice claims. The amendment would have allowed states to create expert panels, administrative health care tribunals, or a combination of the two.
“There’s much stronger support for tort reform among the Republicans in Congress,” Mr. Cardoza said in an interview. “There’s a shot [now]. If the reforms don’t go too far where they would penalize injured patients, I think they could get additional support and be well received by the Congress.”
Tougher abortion restrictions are likely under the Trump administration, experts said. President-elect Trump has said he is committed to nominating a ninth Supreme Court justice who opposes Roe v. Wade.
Vice President-elect Mike Pence, who is considered a strong voice for the religious right, will likely influence who Mr. Trump nominates for the high court, said Rep-elect Raskin, who added that if ever there was time that abortion rights are in jeopardy, it’s now.
“This really puts the Republicans to the test,” he said in an interview. “For decades now, they have been calling for the overruling of Roe v. Wade. The religious right will never forgive them if it doesn’t happen now. [Republicans] control the House, the Senate, and the White House. They have it within their reach to create a five-justice majority on the court.”
[email protected]
[email protected]
On Twitter @legal_med
Look for three things from the Trump administration: significant changes to the Affordable Care Act, few changes to MACRA’s Quality Payment Program, and a conservative swing in the courts.
Republicans have had their sights on the Affordable Care Act since its passage in 2010; with majorities in both the House and the Senate, the question is not if, but when President Obama’s signature piece of legislation will be dismantled.
President-elect Donald Trump ran on the promise of ACA repeal. Health policy priorities on his transition website focus on greater use of health savings accounts, the ability to purchase insurance across state lines, and the reestablishment of high-risk pools.
Health policy experts differ in how they see ACA reform coming about, with some predicting a quick repeal coupled with an immediate legislative replacement, while others envision repeal with more time to craft replacement legislation. Reform also could come as a series of smaller bills rather than one comprehensive package.
Using budget reconciliation would not allow for full ACA repeal since only provisions that involve revenue generation or spending could be altered. However, since budget reconciliation bills cannot be filibustered, only a simple majority is needed for Senate passage. With their razor-thin majority – 51 seats – Republicans will need some support from outside of their own party.
“Twenty-some Democrats, many in very-deep ‘red states’ including North Dakota, are up for reelection in 2018,” Ms. Turner said. “They saw what happened to the candidates who supported Obamacare in 2016 – many of them went down. It happened with Evan Bayh in Indiana, who was running again to reclaim the Senate seat he left in 2010. And the Republican candidate [Todd Young] reminded the voters over and over that Evan Bayh voted for Obamacare. Same thing happened in Wisconsin with [Republican] Sen. Ron Johnson being challenged by Russ Feingold, who also was in the Senate when Obamacare passed. Feingold went down to defeat again. I think the lot of Democratic senators are going to be looking at what happened to those people and think ‘Maybe I better participate in coming up with a more sensible solution.’ ”
More importantly, the GOP may be looking for bipartisan support, especially since the ACA passed on a strict party-line vote. To that end, it could make more sense to delay reform efforts until a broader coalition can be formed and simultaneous repeal/replace package could be brought to both the House and the Senate floors.
In the new Congress, Senate Republicans might face some of the same obstructionist tactics they used during the Obama administration, which could complicate efforts to get bipartisan support.
“When you have people like Sen. [Bernie] Sanders (I-Vt.) and Sen. [Elizabeth] Warren (D-Mass.) saying they are going to adapt a scorched earth approach going forward, they and their followers don’t have any intention of doing anything that would in any way appear to cooperate with the Republicans,” Dr. Wilensky said. “Of course, there are other Democrats, especially some of the ones who will be up in 2018, who might not be quite so adamant.”
“Repeal without a clear idea of what the replacement would be would really throw that market into chaos, where right now we are at a place where the markets are relatively stable,” Dr. Collins said in an interview.“The best way to think about the ACA, and particularly on the marketplaces and what repeal means, is this image of the three-legged stool. The individual market is the seat and the legs include consumer protections, particularly guaranteed issue; the individual requirement to have insurance; and the subsidies to make that coverage affordable – Medicaid expansion is part of that as well. If you start to remove any one of those legs, the market becomes extremely unstable.”
Repealing the individual mandate is problematic as it goes hand in hand with the ban on coverage denial because of preexisting conditions, something President-elect Trump has signaled he is looking to maintain, Ms. Turner said, adding that free market solutions with appropriate incentives could be a different way to encourage healthy people to get coverage to help generate premium revenue to cover patients with preexisting conditions.
While the ACA will be in the crosshairs, experts expect MACRA to remain more or less intact, maybe with some minor tweaks, at least early on.
While the Medicare Access and CHIP Reauthorization Act of 2015 passed with overwhelming support from both parties, “the [implementing regulations] are just a nightmare and I think the Trump administration is going to have to take a look at them,” Ms. Turner said. She added that physicians are weary of the ever-growing federal administrative hassles. “You do not want doctors to leave private practice in droves, and they are looking at this cost of compliance.”
“I think that [MACRA] is just way too much of an in-the-weeds policy thing for the Trump administration to have addressed yet,” Ms. Turner continued. “But this certainly is going to have to be on the agenda because they are going to hear from a lot of doctors that this is not acceptable.”
Mr. Trump also has called for Medicaid reform, with block grants to the states.
“Everyone keeps talking about a block grant, but that is a clumsy way of doing it,” Ms. Turner said, suggesting the program be even more refined to cover people in different baskets, including dual-eligibles, healthy adults that were part of the ACA Medicaid expansion, mothers and infants, and disabled individuals. “A capitated allotment [allows the government to provide more support to] the people who need it.”
Dr. Wilensky suggested that the Trump administration could revisit the 1332 waiver process, another provision of the ACA.
“The current administration has taken a very-rigid view on that you have to keep savings from Medicaid and the ACA separate and any changes have to be budget neutral to each, which is an extremely rigid set of requirements,” she said. Instead “Medicaid and ACA savings could count together and it just needs to be budget neutral over a 3- or 5-year period. That would then allow states to come in and request a lot of flexibility that the current administration hasn’t been inclined to give them.”
Likewise, the Children’s Health Insurance Plan (CHIP) is up for reauthorization. While the program remains relatively popular, it could be due for some reforms as well. Dr. Wilensky said it might be time for the program to go away, though doing that would face resistance from congressional Democrats.
Likewise, Ms. Turner suggested it could be time to fold CHIP into another program like Medicaid.
“Does it really make sense for a mother who is overwhelmed, maybe even with two jobs, to have her kids on a different health insurance program than she’s on?” Ms. Turner said. “It just adds to the burden and the paperwork. Would it make more sense to blend some of these programs together, making sure the people get the health coverage they need, but without all these artificial silos that really make it much more difficult for the user at the other end. I think they are going to take a look at that.”
Whether the ACA is amended or repealed may affect some – but not all – of the ACA-related cases lingering in the courts.
Zubik v. Burwell for instance, may become irrelevant if President-elect Trump eliminates the ACA’s birth control mandate or its accommodation clause. Zubik centers on an exception to the birth control mandate for organizations that oppose coverage for contraceptives but are not exempted entities, such as churches. The plaintiffs argue that the government’s opt-out process makes them complicit in offering contraception coverage indirectly.
The Trump administration could choose to broaden the mandate’s exemption to include the religious organizations, thus satisfying the plaintiffs, said Timothy S. Jost, a health law professor at Washington and Lee University in Lexington, Va., who added that the case would become moot if the ACA is repealed wholesale.
“Millions of women [currently] get access to birth control without cost sharing through the Affordable Care Act,” he said in an interview. “That’s an issue [the new administration] is going to have to confront.”
In March, U.S. Supreme Court justices requested that both sides provide new briefs that outlined how contraception could be provided without requiring notice on the part of the suing employers. Then, in light of the briefs, the high court vacated the lower court rulings related to Zubik and remanded the case to the four appeals courts that had originally ruled on the issue.
If the case makes its way back to the Supreme Court, the ultimate ruling will largely depend on the makeup of the court at the time, said Eric D. Fader, a New York–based health law attorney.
“As long as we have a 4-4 Supreme Court, everything is up in the air,” Mr. Fader said in an interview. “As soon as that ninth slot is filled, I think we’re going to see some decisions that are going to be in line with traditional Republican conservative positions.”
However, a set of ACA-related cases that involve payments to insurers will continue litigating, regardless of actions by the new administration, analysts said. A half-dozen health insurers have sued the Health & Human Services department over alleged underpayments under the ACA’s risk corridor program.
“Even if you do away with the ACA, these cases all pertain to conduct that has already occurred, so they’re not going to be automatically moot,” Mr. Fader said in an interview. “They may struggle along for a while.”
The cases stem from the ACA’s risk corridor program, which requires HHS to collect funds from excessively profitable insurers that offer qualified health plans under the exchanges, while paying out funds to QHP insurers that have excessive losses. Collections from profitable insurers under the program fell short in 2014 and again in 2015, resulting in HHS paying about 12 cents on the dollar in payments to insurers.
The plaintiffs allege they’ve been shortchanged and that the government must reimburse them full payments for 2014. The Department of Justice (DOJ) argues the cases are premature because the full amount owed under the program is not due until 2016, after the program runs its course.
The Trump administration may surrender another ACA-linked challenge that questions billions in payments made to insurers, Mr. Jost said in an interview. In House v. Burwell, the House of Representatives accuses HHS of wrongly spending billions to repay insurers for health insurance provided to certain low-income patients under the ACA. The House claims HHS is illegally spending monies that Congress never appropriated. HHS argues that other statutory provisions of the ACA authorize expenditures for cost-sharing reimbursements. In May, the U.S. District Court for the District of Columbia decided in favor of the House, ruling that Congress never appropriated money for the payments and that no public money can be spent without an appropriation.
There is speculation that the Trump administration may not pursue an appeal, Mr. Jost said. “I think they better think long and hard about that because I don’t know why any president would want court precedent saying one house of Congress can sue the president whenever it disagrees,” he said. “If the Trump administration would give in on the lawsuit or the House would win … there would be some very large losses and some very large premium increases next year. There could be some very significant disruption of insurance markets.”
Again, if the ACA is repealed, the case may become irrelevant, Mr. Fader said. “If you get rid of the ACA and eliminate the cost sharing structure, than House v. Burwell is going to just be moot.”
“We have seen a substantial uptick in antitrust enforcement activity in health care over the last several years,” he said in an interview. “The Trump administration has said that one of its themes is reducing the regulatory burden on businesses. People will be watching to see if that means an attempt to back off of some of the more-aggressive antitrust enforcement activities in health care and other industries.”
The Obama administration is currently fighting to block two mega-mergers among four of the largest health insurers in the nation. The DOJ filed legal challenges earlier this year seeking to ban Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana. The lawsuits allege the mergers – valued at $54 billion and $37 billion respectively – would negatively affect doctors, patients, and employers by limiting price competition, reducing benefits, and lowering quality of care. A majority of physician associations and patient groups oppose the mergers. But experts said the new administration could drop the challenges.
Similarly, the Trump administration could be more lax in its enforcement of the Stark Law. “You could certainly say if the administration is committed to reducing regulatory burden, one thing the administration might push forward is reducing some of the enforcement with respect to technical violations of Stark,” Mr. Horton said, noting that the Senate recently questioned if the government is going too far in regulating physician relationships under Stark. “If your theme is ‘Let’s cut back on regulation,’ that would be an area that you would think the administration would look at.”
Meanwhile, stronger medical malpractice reforms could be on the horizon in light of a Republican-controlled Congress. Tort reform advocates have a good chance at passing federal medical liability reforms that were left out of the ACA’s passage in 2010, said Dennis A. Cardoza, public affairs director and cochair of the federal public affairs practice at a national health law firm.
Earlier versions of the ACA included amendments that mandated lawsuits go through a state or federal alternative dispute resolution system prior to being filed in court. Another provision that failed would have provided federal grants to states that created special health courts for medical malpractice claims. The amendment would have allowed states to create expert panels, administrative health care tribunals, or a combination of the two.
“There’s much stronger support for tort reform among the Republicans in Congress,” Mr. Cardoza said in an interview. “There’s a shot [now]. If the reforms don’t go too far where they would penalize injured patients, I think they could get additional support and be well received by the Congress.”
Tougher abortion restrictions are likely under the Trump administration, experts said. President-elect Trump has said he is committed to nominating a ninth Supreme Court justice who opposes Roe v. Wade.
Vice President-elect Mike Pence, who is considered a strong voice for the religious right, will likely influence who Mr. Trump nominates for the high court, said Rep-elect Raskin, who added that if ever there was time that abortion rights are in jeopardy, it’s now.
“This really puts the Republicans to the test,” he said in an interview. “For decades now, they have been calling for the overruling of Roe v. Wade. The religious right will never forgive them if it doesn’t happen now. [Republicans] control the House, the Senate, and the White House. They have it within their reach to create a five-justice majority on the court.”
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Miguel Angel Villagra Brings Management Skills to The Hospitalist's Volunteer Editorial Advisory Board
Some have called this the “Year of the Hospitalist,” as it’s the 20th anniversary of the New England Journal of Medicine paper by Dr. Robert Wachter and Dr. Lee Goldman that first used the term “hospitalist” to describe physicians who care for hospitalized patients.
But the paper was more than just that to Miguel Angel Villagra, MD.
He saw it four years ago while training in internal medicine at Texas Tech University Health Sciences Center in El Paso, Texas.
“I was very intrigued,” Dr. Villagra says. “I asked a few of my mentors. They were very skeptical on following a hospitalist career, [but] I saw opportunities for improvement and professional growth in the field, so I decided to jump in. And after four years, I don’t regret my decision of becoming a full-time hospitalist.”
The field doesn’t regret it either. Dr. Villagra was promoted last fall to hospitalist department program medical director at White River Medical Center in Batesville, Ark. And this year, he was named one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: At age 11 and after an emergent appendectomy, I decided that I wanted to become a physician. That was one of the best decisions of my life. It is a great combination of art and science, and you get to help people in difficult moments of their life.
Q: Tell us more about your background.
A: I went to medical school in my country of origin at Universidad Autonóma de Nicaragua of Managua, and I did an internal medicine residency at Hospital Militar Escuela Dr. Alejandro Dávila Bolaños. I came to the U.S. for internal medicine residency training at Texas Tech of El Paso. I enjoy learning new skills and this power of knowledge that can help your patients in desperate moments. Most of my challenges during my training involved how to manage stress and sleep deprivation.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were most important lessons you learned from them?
A: Dr. Jorge Cuadra [from Hospital Militar in Nicaragua] and Dr. Manuel Rivera [from Texas Tech], both pulmonologists. They taught me that medicine is a changing field that requires everyday reading. You never end learning new things and approaches. Taking full advantage of your interaction with your patients always improves your clinical skills.
Q: What do you like most about working as a hospitalist?
A: It is an evolving field; we are still trying to “figure it out.” That creates challenges but also opportunities for growth and career development, [for example], how to tackle the readmission problem, how to improve quality at lower cost while keeping patient satisfaction, how to face the burnout challenge and improve physician engagement, just to name a few.
Q: What do you dislike most?
A: In the beginning of my career as a hospitalist, I was exposed constantly to high patient loads that were more than I should have. I also dislike the difficulties at times of electronic medical records. You have to spend excessive time sitting in front of a monitor.
Q: You note the challenges the field of HM is facing. How exciting is it to hopefully be part of the solutions?
A: I feel pumped having been part of this amazing movement of hospital medicine. I think we are leading the change from the acute-care setting front line, helping to take better care of our patients. The current healthcare changes create multiple challenges and, along with that, endless opportunities for professional growth and career development.
Q: You’ve said you see being a chief quality officer in the future. Why? What appeals about those C-suite positions?
A: I think that physicians as leaders are in a great position to drive the change within a healthcare organization toward high-value care. We are at the front line, at the bedside taking care of patients. That gives us firsthand information on what needs to be done. With appropriate training, we can be the executives the institution needs. When I started my role as medical director, initially I focused mainly on managing the group, but rapidly I was involved in several quality projects and academic activities. And soon I realized that I can have a broader impact on what I was doing, going beyond the bedside where you try to offer the best care possible for your patients to an organizational level of change.
Q: How has your journey from Nicaragua to the U.S. shaped you, and how has it shaped the way you practice medicine?
A: Certainly it shaped what I am today, coming from a country that struggles with poverty. During medical school, you lack advances in technology and depend mainly on your desire to excel and be better for the benefit of your patients. You build strong clinical skills from history to physical exam. When you move to the U.S. and have access to so many technological advances, from new diagnostic tests to top-of the-line imaging studies, you combine the best of both worlds, and [that] makes you a better physician. I am very proud of my heritage, and definitely I wouldn’t change anything on my path thus far. I believe the more you overcome difficulties and adversities, the more you appreciate what you accomplished.
Q: As a group leader, why is it important for you to continue seeing patients?
A: We lead our teams by example, and that requires treating patients. I am also a clinician, and I love my profession, so I don’t foresee myself only in an administrative role. Finding the sweet spot of clinician-administrative time is very difficult, and I am still working on it.
Q: What’s the best advice you ever received?
A: Read and learn every day, be good to people, and also dream big.
Q: What’s the worst advice you ever received?
A: Never get married. I didn’t listen.
Richard Quinn is a freelance writer in New Jersey.
Some have called this the “Year of the Hospitalist,” as it’s the 20th anniversary of the New England Journal of Medicine paper by Dr. Robert Wachter and Dr. Lee Goldman that first used the term “hospitalist” to describe physicians who care for hospitalized patients.
But the paper was more than just that to Miguel Angel Villagra, MD.
He saw it four years ago while training in internal medicine at Texas Tech University Health Sciences Center in El Paso, Texas.
“I was very intrigued,” Dr. Villagra says. “I asked a few of my mentors. They were very skeptical on following a hospitalist career, [but] I saw opportunities for improvement and professional growth in the field, so I decided to jump in. And after four years, I don’t regret my decision of becoming a full-time hospitalist.”
The field doesn’t regret it either. Dr. Villagra was promoted last fall to hospitalist department program medical director at White River Medical Center in Batesville, Ark. And this year, he was named one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: At age 11 and after an emergent appendectomy, I decided that I wanted to become a physician. That was one of the best decisions of my life. It is a great combination of art and science, and you get to help people in difficult moments of their life.
Q: Tell us more about your background.
A: I went to medical school in my country of origin at Universidad Autonóma de Nicaragua of Managua, and I did an internal medicine residency at Hospital Militar Escuela Dr. Alejandro Dávila Bolaños. I came to the U.S. for internal medicine residency training at Texas Tech of El Paso. I enjoy learning new skills and this power of knowledge that can help your patients in desperate moments. Most of my challenges during my training involved how to manage stress and sleep deprivation.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were most important lessons you learned from them?
A: Dr. Jorge Cuadra [from Hospital Militar in Nicaragua] and Dr. Manuel Rivera [from Texas Tech], both pulmonologists. They taught me that medicine is a changing field that requires everyday reading. You never end learning new things and approaches. Taking full advantage of your interaction with your patients always improves your clinical skills.
Q: What do you like most about working as a hospitalist?
A: It is an evolving field; we are still trying to “figure it out.” That creates challenges but also opportunities for growth and career development, [for example], how to tackle the readmission problem, how to improve quality at lower cost while keeping patient satisfaction, how to face the burnout challenge and improve physician engagement, just to name a few.
Q: What do you dislike most?
A: In the beginning of my career as a hospitalist, I was exposed constantly to high patient loads that were more than I should have. I also dislike the difficulties at times of electronic medical records. You have to spend excessive time sitting in front of a monitor.
Q: You note the challenges the field of HM is facing. How exciting is it to hopefully be part of the solutions?
A: I feel pumped having been part of this amazing movement of hospital medicine. I think we are leading the change from the acute-care setting front line, helping to take better care of our patients. The current healthcare changes create multiple challenges and, along with that, endless opportunities for professional growth and career development.
Q: You’ve said you see being a chief quality officer in the future. Why? What appeals about those C-suite positions?
A: I think that physicians as leaders are in a great position to drive the change within a healthcare organization toward high-value care. We are at the front line, at the bedside taking care of patients. That gives us firsthand information on what needs to be done. With appropriate training, we can be the executives the institution needs. When I started my role as medical director, initially I focused mainly on managing the group, but rapidly I was involved in several quality projects and academic activities. And soon I realized that I can have a broader impact on what I was doing, going beyond the bedside where you try to offer the best care possible for your patients to an organizational level of change.
Q: How has your journey from Nicaragua to the U.S. shaped you, and how has it shaped the way you practice medicine?
A: Certainly it shaped what I am today, coming from a country that struggles with poverty. During medical school, you lack advances in technology and depend mainly on your desire to excel and be better for the benefit of your patients. You build strong clinical skills from history to physical exam. When you move to the U.S. and have access to so many technological advances, from new diagnostic tests to top-of the-line imaging studies, you combine the best of both worlds, and [that] makes you a better physician. I am very proud of my heritage, and definitely I wouldn’t change anything on my path thus far. I believe the more you overcome difficulties and adversities, the more you appreciate what you accomplished.
Q: As a group leader, why is it important for you to continue seeing patients?
A: We lead our teams by example, and that requires treating patients. I am also a clinician, and I love my profession, so I don’t foresee myself only in an administrative role. Finding the sweet spot of clinician-administrative time is very difficult, and I am still working on it.
Q: What’s the best advice you ever received?
A: Read and learn every day, be good to people, and also dream big.
Q: What’s the worst advice you ever received?
A: Never get married. I didn’t listen.
Richard Quinn is a freelance writer in New Jersey.
Some have called this the “Year of the Hospitalist,” as it’s the 20th anniversary of the New England Journal of Medicine paper by Dr. Robert Wachter and Dr. Lee Goldman that first used the term “hospitalist” to describe physicians who care for hospitalized patients.
But the paper was more than just that to Miguel Angel Villagra, MD.
He saw it four years ago while training in internal medicine at Texas Tech University Health Sciences Center in El Paso, Texas.
“I was very intrigued,” Dr. Villagra says. “I asked a few of my mentors. They were very skeptical on following a hospitalist career, [but] I saw opportunities for improvement and professional growth in the field, so I decided to jump in. And after four years, I don’t regret my decision of becoming a full-time hospitalist.”
The field doesn’t regret it either. Dr. Villagra was promoted last fall to hospitalist department program medical director at White River Medical Center in Batesville, Ark. And this year, he was named one of eight new members of Team Hospitalist, The Hospitalist’s volunteer editorial advisory board.
Question: Why did you choose a career in medicine?
Answer: At age 11 and after an emergent appendectomy, I decided that I wanted to become a physician. That was one of the best decisions of my life. It is a great combination of art and science, and you get to help people in difficult moments of their life.
Q: Tell us more about your background.
A: I went to medical school in my country of origin at Universidad Autonóma de Nicaragua of Managua, and I did an internal medicine residency at Hospital Militar Escuela Dr. Alejandro Dávila Bolaños. I came to the U.S. for internal medicine residency training at Texas Tech of El Paso. I enjoy learning new skills and this power of knowledge that can help your patients in desperate moments. Most of my challenges during my training involved how to manage stress and sleep deprivation.
Q: Did you have a mentor during your training or early career? If so, who was the mentor, and what were most important lessons you learned from them?
A: Dr. Jorge Cuadra [from Hospital Militar in Nicaragua] and Dr. Manuel Rivera [from Texas Tech], both pulmonologists. They taught me that medicine is a changing field that requires everyday reading. You never end learning new things and approaches. Taking full advantage of your interaction with your patients always improves your clinical skills.
Q: What do you like most about working as a hospitalist?
A: It is an evolving field; we are still trying to “figure it out.” That creates challenges but also opportunities for growth and career development, [for example], how to tackle the readmission problem, how to improve quality at lower cost while keeping patient satisfaction, how to face the burnout challenge and improve physician engagement, just to name a few.
Q: What do you dislike most?
A: In the beginning of my career as a hospitalist, I was exposed constantly to high patient loads that were more than I should have. I also dislike the difficulties at times of electronic medical records. You have to spend excessive time sitting in front of a monitor.
Q: You note the challenges the field of HM is facing. How exciting is it to hopefully be part of the solutions?
A: I feel pumped having been part of this amazing movement of hospital medicine. I think we are leading the change from the acute-care setting front line, helping to take better care of our patients. The current healthcare changes create multiple challenges and, along with that, endless opportunities for professional growth and career development.
Q: You’ve said you see being a chief quality officer in the future. Why? What appeals about those C-suite positions?
A: I think that physicians as leaders are in a great position to drive the change within a healthcare organization toward high-value care. We are at the front line, at the bedside taking care of patients. That gives us firsthand information on what needs to be done. With appropriate training, we can be the executives the institution needs. When I started my role as medical director, initially I focused mainly on managing the group, but rapidly I was involved in several quality projects and academic activities. And soon I realized that I can have a broader impact on what I was doing, going beyond the bedside where you try to offer the best care possible for your patients to an organizational level of change.
Q: How has your journey from Nicaragua to the U.S. shaped you, and how has it shaped the way you practice medicine?
A: Certainly it shaped what I am today, coming from a country that struggles with poverty. During medical school, you lack advances in technology and depend mainly on your desire to excel and be better for the benefit of your patients. You build strong clinical skills from history to physical exam. When you move to the U.S. and have access to so many technological advances, from new diagnostic tests to top-of the-line imaging studies, you combine the best of both worlds, and [that] makes you a better physician. I am very proud of my heritage, and definitely I wouldn’t change anything on my path thus far. I believe the more you overcome difficulties and adversities, the more you appreciate what you accomplished.
Q: As a group leader, why is it important for you to continue seeing patients?
A: We lead our teams by example, and that requires treating patients. I am also a clinician, and I love my profession, so I don’t foresee myself only in an administrative role. Finding the sweet spot of clinician-administrative time is very difficult, and I am still working on it.
Q: What’s the best advice you ever received?
A: Read and learn every day, be good to people, and also dream big.
Q: What’s the worst advice you ever received?
A: Never get married. I didn’t listen.
Richard Quinn is a freelance writer in New Jersey.
How NPs and PAs Work with HM Groups
While the role of nurse practitioners (NPs) and physician assistants (PAs) in hospital medicine is far from uniform, data from the 2016 State of Hospital Medicine Report show that a majority of hospital medicine groups utilize NPs or PAs. Over the past decade, the percentage of hospital medicine groups that include NPs or PAs has grown from about 20% in 20051 to 65% in 2015.2
I suspect a large part of this growth is fueled by demand continuing to outstrip supply for hospitalist physicians and continued increases in hospitalist salaries. In academic institutions, restrictions in house staff duty hours over the past decade no doubt also contributed to the growth of NP and PA utilization.
How Should HM Groups Use NPs and PAs?
In addition to obtaining group buy-in prior to deploying NPs or PAs in a hospital medicine group, a thoughtful consideration about the role of NPs or PAs in providing care is perhaps most important. Even with careful planning, groups should expect implementation of an NP or PA model to require lead-in and training time.
The fact that NPs and PAs have been adopted by so many groups suggests that practices have found increased value; however, models vary widely. In some practices, NPs or PAs work side by side with hospitalists, assisting with documentation, meeting with patients and families, and implementing an agreed-upon management plan. In this model, NPs and PAs may also add value by helping with time-consuming discharges, freeing hospitalists to attend to other patients and thus improving productivity, bed flow, and perhaps also job sustainability.
Other groups have found niche roles for NPs or PAs, including but not limited to providing cross-coverage, performing procedures, triaging admissions, staffing observation units, and developing expertise in a specific clinical area such as consultative medicine or orthopedics.
How to Bill
Depending on the model adopted, groups must also decide whether it is advantageous for NPs or PAs to bill for services independently versus as shared services under the supervising physician’s provider number. The Centers for Medicare & Medicaid Services reimburses NPs and PAs who bill independently at 85% of the physician rate. Nonetheless, some groups may find it more cost-effective for NPs or PAs to bill independently given the substantial salary differential compared to hospitalists. Data published in the 2016 State of Hospital Medicine Report show that NPs and PAs bill independently 47.9% of the time (see Figure 1).
At the University of California, San Diego, we’ve found that our PAs added the most value when working one-on-one with a single hospitalist rather than with multiple physicians. Specifically, our PAs have added to the capacity of our non-teaching service, typically implementing a plan of care developed cooperatively with the hospitalist but also managing a select cohort of patients independently during times of excess volume. By increasing capacity, our PAs have also allowed us to avoid calling in a backup hospitalist during high census periods.
References
- Society of Hospital Medicine. 2006 State of Hospital Medicine Report.
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed October 23, 2016.
While the role of nurse practitioners (NPs) and physician assistants (PAs) in hospital medicine is far from uniform, data from the 2016 State of Hospital Medicine Report show that a majority of hospital medicine groups utilize NPs or PAs. Over the past decade, the percentage of hospital medicine groups that include NPs or PAs has grown from about 20% in 20051 to 65% in 2015.2
I suspect a large part of this growth is fueled by demand continuing to outstrip supply for hospitalist physicians and continued increases in hospitalist salaries. In academic institutions, restrictions in house staff duty hours over the past decade no doubt also contributed to the growth of NP and PA utilization.
How Should HM Groups Use NPs and PAs?
In addition to obtaining group buy-in prior to deploying NPs or PAs in a hospital medicine group, a thoughtful consideration about the role of NPs or PAs in providing care is perhaps most important. Even with careful planning, groups should expect implementation of an NP or PA model to require lead-in and training time.
The fact that NPs and PAs have been adopted by so many groups suggests that practices have found increased value; however, models vary widely. In some practices, NPs or PAs work side by side with hospitalists, assisting with documentation, meeting with patients and families, and implementing an agreed-upon management plan. In this model, NPs and PAs may also add value by helping with time-consuming discharges, freeing hospitalists to attend to other patients and thus improving productivity, bed flow, and perhaps also job sustainability.
Other groups have found niche roles for NPs or PAs, including but not limited to providing cross-coverage, performing procedures, triaging admissions, staffing observation units, and developing expertise in a specific clinical area such as consultative medicine or orthopedics.
How to Bill
Depending on the model adopted, groups must also decide whether it is advantageous for NPs or PAs to bill for services independently versus as shared services under the supervising physician’s provider number. The Centers for Medicare & Medicaid Services reimburses NPs and PAs who bill independently at 85% of the physician rate. Nonetheless, some groups may find it more cost-effective for NPs or PAs to bill independently given the substantial salary differential compared to hospitalists. Data published in the 2016 State of Hospital Medicine Report show that NPs and PAs bill independently 47.9% of the time (see Figure 1).
At the University of California, San Diego, we’ve found that our PAs added the most value when working one-on-one with a single hospitalist rather than with multiple physicians. Specifically, our PAs have added to the capacity of our non-teaching service, typically implementing a plan of care developed cooperatively with the hospitalist but also managing a select cohort of patients independently during times of excess volume. By increasing capacity, our PAs have also allowed us to avoid calling in a backup hospitalist during high census periods.
References
- Society of Hospital Medicine. 2006 State of Hospital Medicine Report.
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed October 23, 2016.
While the role of nurse practitioners (NPs) and physician assistants (PAs) in hospital medicine is far from uniform, data from the 2016 State of Hospital Medicine Report show that a majority of hospital medicine groups utilize NPs or PAs. Over the past decade, the percentage of hospital medicine groups that include NPs or PAs has grown from about 20% in 20051 to 65% in 2015.2
I suspect a large part of this growth is fueled by demand continuing to outstrip supply for hospitalist physicians and continued increases in hospitalist salaries. In academic institutions, restrictions in house staff duty hours over the past decade no doubt also contributed to the growth of NP and PA utilization.
How Should HM Groups Use NPs and PAs?
In addition to obtaining group buy-in prior to deploying NPs or PAs in a hospital medicine group, a thoughtful consideration about the role of NPs or PAs in providing care is perhaps most important. Even with careful planning, groups should expect implementation of an NP or PA model to require lead-in and training time.
The fact that NPs and PAs have been adopted by so many groups suggests that practices have found increased value; however, models vary widely. In some practices, NPs or PAs work side by side with hospitalists, assisting with documentation, meeting with patients and families, and implementing an agreed-upon management plan. In this model, NPs and PAs may also add value by helping with time-consuming discharges, freeing hospitalists to attend to other patients and thus improving productivity, bed flow, and perhaps also job sustainability.
Other groups have found niche roles for NPs or PAs, including but not limited to providing cross-coverage, performing procedures, triaging admissions, staffing observation units, and developing expertise in a specific clinical area such as consultative medicine or orthopedics.
How to Bill
Depending on the model adopted, groups must also decide whether it is advantageous for NPs or PAs to bill for services independently versus as shared services under the supervising physician’s provider number. The Centers for Medicare & Medicaid Services reimburses NPs and PAs who bill independently at 85% of the physician rate. Nonetheless, some groups may find it more cost-effective for NPs or PAs to bill independently given the substantial salary differential compared to hospitalists. Data published in the 2016 State of Hospital Medicine Report show that NPs and PAs bill independently 47.9% of the time (see Figure 1).
At the University of California, San Diego, we’ve found that our PAs added the most value when working one-on-one with a single hospitalist rather than with multiple physicians. Specifically, our PAs have added to the capacity of our non-teaching service, typically implementing a plan of care developed cooperatively with the hospitalist but also managing a select cohort of patients independently during times of excess volume. By increasing capacity, our PAs have also allowed us to avoid calling in a backup hospitalist during high census periods.
References
- Society of Hospital Medicine. 2006 State of Hospital Medicine Report.
- 2016 State of Hospital Medicine Report. Society of Hospital Medicine website. Accessed October 23, 2016.
SHM Commits to Help Hospitals with Judicious Opioid Prescribing
SHM recently enrolled 10 hospitals in the United States in a one-year mentored implementation program to reduce adverse events associated with opioid prescribing. Each hospital will have an assigned physician mentor to guide them through:
- A needs assessment.
- Formal selection of data collection measures.
- Outcome and process data collection on intervention units.
- Design and implementation of key interventions to enhance safety for patients in the hospital who are prescribed opioid medications.
The one-year program includes monthly calls, a site visit with the SHM physician mentor, and a formal assessment of the program’s implementation.
Visit www.hospitalmedicine.org/RADEO to view the online toolkit or download the Reducing Adverse Drug Events Related to Opioids (RADEO) Implementation Guide.
SHM recently enrolled 10 hospitals in the United States in a one-year mentored implementation program to reduce adverse events associated with opioid prescribing. Each hospital will have an assigned physician mentor to guide them through:
- A needs assessment.
- Formal selection of data collection measures.
- Outcome and process data collection on intervention units.
- Design and implementation of key interventions to enhance safety for patients in the hospital who are prescribed opioid medications.
The one-year program includes monthly calls, a site visit with the SHM physician mentor, and a formal assessment of the program’s implementation.
Visit www.hospitalmedicine.org/RADEO to view the online toolkit or download the Reducing Adverse Drug Events Related to Opioids (RADEO) Implementation Guide.
SHM recently enrolled 10 hospitals in the United States in a one-year mentored implementation program to reduce adverse events associated with opioid prescribing. Each hospital will have an assigned physician mentor to guide them through:
- A needs assessment.
- Formal selection of data collection measures.
- Outcome and process data collection on intervention units.
- Design and implementation of key interventions to enhance safety for patients in the hospital who are prescribed opioid medications.
The one-year program includes monthly calls, a site visit with the SHM physician mentor, and a formal assessment of the program’s implementation.
Visit www.hospitalmedicine.org/RADEO to view the online toolkit or download the Reducing Adverse Drug Events Related to Opioids (RADEO) Implementation Guide.
Track List Available for Hospital Medicine 2017
Looking for more? Seize the opportunity to learn from an elite group of experts. Earn additional CME credits, broaden your skills, and fine-tune your practice. Immerse yourself in a day of learning by enrolling in one six pre-courses on May 1. Visit www.hospitalmedicine2017.org/precourse to view course topics, agendas, faculty, and more.
Looking for more? Seize the opportunity to learn from an elite group of experts. Earn additional CME credits, broaden your skills, and fine-tune your practice. Immerse yourself in a day of learning by enrolling in one six pre-courses on May 1. Visit www.hospitalmedicine2017.org/precourse to view course topics, agendas, faculty, and more.
Looking for more? Seize the opportunity to learn from an elite group of experts. Earn additional CME credits, broaden your skills, and fine-tune your practice. Immerse yourself in a day of learning by enrolling in one six pre-courses on May 1. Visit www.hospitalmedicine2017.org/precourse to view course topics, agendas, faculty, and more.
Thinking Outside the DRG Box
When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.
Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.
However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).
What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.
To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.
Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):
Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.
Reference
Clinician lists. Choosing Wisely website. Accessed October 25, 2016.
When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.
Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.
However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).
What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.
To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.
Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):
Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.
Reference
Clinician lists. Choosing Wisely website. Accessed October 25, 2016.
When choosing quality improvement activities, hospitalists have no shortage of choices. In this column, I offer a strategic guide for hospitalists as they assess where best to spend their energy as the shift to value-based care progresses. This includes the introduction of MACRA, the landmark new payment program for doctors and other clinicians (aka the Medicare Access and CHIP Reauthorization Act of 2015), with its incentives for participation in alternative payment models.
Since 1983, Medicare has reimbursed hospitals using a lump-sum payment known as a diagnosis-related group, or DRG. Since then, hospitals have focused a good deal of their energy on removing needless expenses from the hospitalization to improve their bottom line, recognizing the DRG payment they receive is relatively fixed. To this end, a major strategy has been to use hospitalists to decrease length of stay and “right size” the utilization of in-hospital tests and treatments.
However, things are changing as we enter the era of alternative payment models such as accountable care organizations (ACOs) and bundled payments. The lens Medicare (and, to a great extent, commercial payors) peers through to assess inpatient hospital costs is the DRG payment amount. Beyond that, Medicare has little visibility into the actual costs hospitals incur. Since hospital spending equates to the payment amount for a DRG, it becomes apparent that the incremental opportunity for hospitalists to improve value (quality divided by cost) in alternative payment models stems from payments outside the DRG. Such payments include those related to the post-acute period such as nursing and rehabilitation facilities, readmissions, and part B activity (e.g., consultants and outpatient tests).
What does this mean for hospitalists? MACRA begins in 2019, but initial payments will be based on 2017 performance. The associated advantage of participating in an “advanced alternative payment model” where there is accountability for care beyond the hospitalization is that hospitalists will be rewarded for taking costs out of the post-acute time period.
To be clear, hospitalists should remain agents of in-hospital efficiency and quality. After all, that is how we add value to the hospitals in which we practice. All things being equal, however, hospitalists should focus on practices that will improve value beyond the four walls of the hospital.
Here is my shortlist of these practices. While there is crossover between the categories, I divide the practices into those that improve value during the DRG period and also post-DRG and those that improve value primarily post-DRG (thanks to Choosing Wisely for contributing to the recommendations with an asterisk1):
Thinking outside the DRG box will require an adjustment to the approach taken by hospitalists because the current demands are often more than enough for a day’s work. Hospitalists will be called upon to innovate and fashion better approaches to care. This will require support by other members of the healthcare team so hospitalists can work smarter, not harder, to meet the requirements of a changing healthcare system. A prerequisite is better payment models that align financial incentives so that providing higher-value care is sustainable and appropriately rewarded.
Reference
Clinician lists. Choosing Wisely website. Accessed October 25, 2016.
Tips for Working with Difficult Doctors
As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1
The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.
“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.
Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:
- foster medical errors;
- contribute to poor patient satisfaction;
- contribute to preventable adverse outcomes;
- increase the cost of care;
- undermine team effectiveness; and
- cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1
“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.
At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2
One bad hospitalist can bring down the reputation of an entire team.
“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.
The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.
The Roots of Evil
Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1
Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1
According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.
“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”
Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.
“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.
Confronting Those Who Misbehave
Dr. Zipper says physicians should confront behavioral issues directly.
“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”
At times, it may not be possible to discuss an emergent matter, such as during a code blue.
“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”
For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1
If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.
Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1
Helping Difficult Doctors
After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.
“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.
Troutman suggests enlisting the assistance of a respected peer.
“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”
If an employee has a recent change in behavior, ask if there is a reason.
“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.
Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.
“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”
Dismissing Bad Employees
After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.
“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”
Karen Appold is a medical writer in Pennsylvania.
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
- Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
Are Behaviors Getting Better or Worse?
The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.
According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2
- 73% reported encountering negative comments about colleagues or leaders during the previous year.
- 68% reported condescending language or demeaning comments or insults.
- 77% said they had encountered reluctance or refusal to answer questions or return calls.
- 69% reported they had encountered impatience with questions or hanging up the phone.
In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3
Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”
As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.
“This is a critical piece to having a sound patient safety system,” he says.
In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:
- Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
- Is leadership committed to decreasing these types of behaviors?
- Is there a reporting system in place, and is it being used, monitored, and acted on?
- Can leadership step in and enforce the process if physicians aren’t complying?
- Is a model in place if intervention is necessary?
According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4
Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.
—Karen Appold
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
- MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
- Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.
Proceed with Caution When Hiring Staff
Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.
In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.
“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.
“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”
Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.
Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.
If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?
“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.
Fuller advises differently.
“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.
Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.
—Karen Appold
As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1
The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.
“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.
Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:
- foster medical errors;
- contribute to poor patient satisfaction;
- contribute to preventable adverse outcomes;
- increase the cost of care;
- undermine team effectiveness; and
- cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1
“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.
At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2
One bad hospitalist can bring down the reputation of an entire team.
“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.
The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.
The Roots of Evil
Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1
Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1
According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.
“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”
Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.
“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.
Confronting Those Who Misbehave
Dr. Zipper says physicians should confront behavioral issues directly.
“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”
At times, it may not be possible to discuss an emergent matter, such as during a code blue.
“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”
For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1
If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.
Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1
Helping Difficult Doctors
After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.
“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.
Troutman suggests enlisting the assistance of a respected peer.
“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”
If an employee has a recent change in behavior, ask if there is a reason.
“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.
Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.
“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”
Dismissing Bad Employees
After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.
“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”
Karen Appold is a medical writer in Pennsylvania.
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
- Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
Are Behaviors Getting Better or Worse?
The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.
According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2
- 73% reported encountering negative comments about colleagues or leaders during the previous year.
- 68% reported condescending language or demeaning comments or insults.
- 77% said they had encountered reluctance or refusal to answer questions or return calls.
- 69% reported they had encountered impatience with questions or hanging up the phone.
In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3
Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”
As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.
“This is a critical piece to having a sound patient safety system,” he says.
In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:
- Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
- Is leadership committed to decreasing these types of behaviors?
- Is there a reporting system in place, and is it being used, monitored, and acted on?
- Can leadership step in and enforce the process if physicians aren’t complying?
- Is a model in place if intervention is necessary?
According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4
Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.
—Karen Appold
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
- MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
- Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.
Proceed with Caution When Hiring Staff
Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.
In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.
“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.
“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”
Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.
Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.
If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?
“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.
Fuller advises differently.
“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.
Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.
—Karen Appold
As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1
The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.
“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.
Unruly physicians don’t just annoy their coworkers. According to a sentinel event alert from The Joint Commission, they can:
- foster medical errors;
- contribute to poor patient satisfaction;
- contribute to preventable adverse outcomes;
- increase the cost of care;
- undermine team effectiveness; and
- cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1
“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.
At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2
One bad hospitalist can bring down the reputation of an entire team.
“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.
The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.
The Roots of Evil
Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1
Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1
According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.
“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”
Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.
“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.
Confronting Those Who Misbehave
Dr. Zipper says physicians should confront behavioral issues directly.
“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”
At times, it may not be possible to discuss an emergent matter, such as during a code blue.
“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”
For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1
If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.
Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1
Helping Difficult Doctors
After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.
“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.
Troutman suggests enlisting the assistance of a respected peer.
“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”
If an employee has a recent change in behavior, ask if there is a reason.
“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.
Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.
“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”
Dismissing Bad Employees
After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.
“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”
Karen Appold is a medical writer in Pennsylvania.
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
- Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.
Are Behaviors Getting Better or Worse?
The Joint Commission issued a sentinel event alert1 on July 9, 2008, as a result of continuous reports to the commission’s Office of Quality and Patient Safety about disruptive behavior. Despite efforts to prevent employees from behaving badly, Ronald Wyatt, MD, MHA, medical director of the Division of Healthcare Improvement, says there is no evidence that the number of instances of bad behavior is decreasing.
According to a 2013 Institute for Safe Medication Practices survey with 4,884 respondents:2
- 73% reported encountering negative comments about colleagues or leaders during the previous year.
- 68% reported condescending language or demeaning comments or insults.
- 77% said they had encountered reluctance or refusal to answer questions or return calls.
- 69% reported they had encountered impatience with questions or hanging up the phone.
In addition, in a 2011 survey of more than 500 physician leaders and more than 300 staff physicians, 71 percent of respondents stated they had witnessed some type of disruptive behavior within the previous month, while 26 percent stated that they had been disruptive at one point in their career.3
Despite the gloomy news, Dr. Wyatt says, “There is increased awareness of disruptive behaviors, and they are being reported more often than in the past.”
As a former chief of medicine at a hospital, Dr. Wyatt says the lack of improvement could be due to hospital leadership.
“This is a critical piece to having a sound patient safety system,” he says.
In order for bad behaviors to improve, hospital leadership needs to be committed to creating a culture of safety. This would involve answering “yes” to the following questions:
- Does staff feel safe to report disruptive behaviors, and will leadership act on those reports?
- Is leadership committed to decreasing these types of behaviors?
- Is there a reporting system in place, and is it being used, monitored, and acted on?
- Can leadership step in and enforce the process if physicians aren’t complying?
- Is a model in place if intervention is necessary?
According to Dr. Wyatt, data show that one intervention is usually enough for most physicians to cease bad behaviors, but a small portion will persist.4
Hospitals accredited by The Joint Commission can contact the organization for a template regarding a policy for disruptive behaviors. Some consultants can also provide this.
—Karen Appold
References
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Patient safety systems. Comprehensive Accreditation Manual for Hospitals. The Joint Commission. January 1, 2015:7-8.
- MacDonald O. Disruptive physician behavior. Quantia Communications, Inc.: Waltham, MA. May 15, 2011.
- Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.
Proceed with Caution When Hiring Staff
Ideally, an institution won’t hire someone with intimidating and disruptive behavior in the first place. But this is always easier said than done.
In an effort to select and hire the best employees, it is important during the interview process to ask many questions about a candidate’s prior experiences and previous bosses as well as what the employee perceives to be good behavior and reasonable expectations.
“Listen for victim-like responses and criticisms of prior supervisors or employers,” says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive. “Such responses are red flags that may help predict how the applicant will work out in your organization.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, says it’s best for the candidate to have interviews with multiple staff members in different ranks.
“Sometimes people will show a different side if he or she perceives someone as unimportant or someone that he or she could boss around,” he says. “The interview can be very telling if the applicant is a cultural fit or not.”
Carefully check a candidate’s previous training and employment records. It can be difficult, however, to decipher whether a potential employee will indeed be a good choice because prior employers almost uniformly refuse to provide more than someone’s position and dates of employment when references are checked, says Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles.
Consequently, Fuller recommends that hospitals have very specific probation policies, allowing for termination for any reason within the first 90 days of employment and active supervision of new employees to ensure that no red flags are raised within that time frame.
If someone was fired from a previous job, use extra caution in making a hiring decision. Paskoff advises considering the facts: What was the person fired for? What do his or her records look like?
“Just because someone was fired, you shouldn’t dismiss him or her, but know what he or she was fired for and how well the firing was documented and investigated,” he says.
Fuller advises differently.
“If proper policies were followed and the employee failed to comport with improvement recommendations, he or she is not going to be any different the second time around,” he says.
Although the job interview process can be lengthy, “don’t take any shortcuts,” Paskoff says. You may end up costing an organization a lot more than time if you do.
—Karen Appold
VIDEO: Tips & Strategies for the Hospital Medicine Job Search
Dr. Thomas Frederickson, Dr. Benjamin Frizner, and Dr. Darlene Tad-y are all experienced at hiring and mentoring hospitalists at all career stages. They offer tips and strategies for assessing opportunity and negotiating your ideal HM job.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Thomas Frederickson, Dr. Benjamin Frizner, and Dr. Darlene Tad-y are all experienced at hiring and mentoring hospitalists at all career stages. They offer tips and strategies for assessing opportunity and negotiating your ideal HM job.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Thomas Frederickson, Dr. Benjamin Frizner, and Dr. Darlene Tad-y are all experienced at hiring and mentoring hospitalists at all career stages. They offer tips and strategies for assessing opportunity and negotiating your ideal HM job.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
