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REPORT: Nearly Half of Resident Physicians Report Burnout

REPORT: Nearly Half of Resident Physicians Report Burnout

ROCHESTER, Minn. – Resident physician burnout in the U.S. is widespread, with the highest rates concentrated in certain specialties, according to research from Mayo Clinic, OHSU and collaborators. The findings appear in the Journal of the American Medical Association. Physician burnout is a dangerous mix of exhaustion and depersonalization that contributes to physicians making mistakes while administering health care.

The study found 45 percent of respondents experienced at least one major symptom of burnout, with those in urology, neurology, emergency medicine and general surgery at the highest risk. Regardless of specialty, high levels of anxiety and low levels of empathy reported during medical school were associated with burnout symptoms during residency.

“Our data show wide variability in the prevalence of burnout by clinical specialty, and that anxiety, social support and empathy during medical school relate to the risk of burnout during residency,” says Liselotte Dyrbye, M.D., a Mayo Clinic researcher and first author of the article.

Residents with burnout had more than a threefold increase in odds of regretting their decision to become a physician. When asked, “If you could revisit your career choice, would you choose to become a physician again?” those in pathology and anesthesiology were also most likely to respond “definitely not” or “probably not.” Similarly, the higher the level of anxiety reported during medical school, the greater the chance of regretting becoming a physician.

Previous research has shown physician burnout has some relation to gender and ethnicity. Residents who identified as female had a higher risk of burnout symptoms, matching studies of later-career physicians.

Although the problems facing female physicians have been reported, the study illustrated the less-studied plight of residents who self-identified as Latino or Hispanic. These individuals were more likely to regret their specialty choice. While the study did not examine the cause directly, the authors speculate that minority physicians often are pressed into participating in various institutional diversity initiatives that overtax their schedules compared to nonminority physicians.

Not all of the study’s findings were negative. The majority of residents are satisfied with their career choice and specialty. In particular, participants who reported high empathy scores during medical school appeared to be more resilient to burnout during residency. This is counter to the common narrative that physicians need “thick skin” or an emotional aloofness to perform.  Similarly, high empathy scores during medical school were associated with a willingness to choose the same specialty again. In addition, participants who reported higher emotional social support during medical school were generally happier with their specialty choice.

Other burnout studies have focused on physicians-in-practice. This was the first national study to longitudinally follow medical trainees from the beginning of medical school into residency to explore predictors of burnout. The study included nearly 3,600 participants who were surveyed in the fourth year of medical school with follow-up in second year of residency. It was derived from a larger study of medical students called the Cognitive Habits and Growth Evaluation Study that has tracked a group of students from their first year of medical school through the last year of residency.

About 50 medical schools were included in the research. Residents were asked to provide information about their specialty, ethnicity, educational debt and other demographic characteristics. They then completed surveys that have previously been developed to measure anxiety, emotional social support, empathy and burnout.

The study was supported by a grant from the National Heart, Lung and Blood Institute, and the Mayo Clinic Department of Medicine Program on Physician Well-Being. Researchers from Mayo Clinic, Syracuse University, University of Minnesota, Yale University, Stanford School of Medicine, and OHSU distributed, collected and analyzed the surveys. Michelle van Ryn, Ph.D., OHSU School of Nursing was the principal investigator.

 

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Let’s Talk About Physician Burnout

Let’s Talk About Physician Burnout

According to Medscape’s 2018 Annual Physician Lifestyle Report, Burnout and Depression Section, 42 percent of physicians surveyed have reported burnout symptoms in the last year. Fifteen percent of physicians admitted to experiencing either clinical or colloquial forms of depression. The National Institute of Mental Health reports 6.7 percent of all American adults suffered at least one major depressive episode in the past year.

To say that burnout and depression have reached epidemic proportions among the medical community is an understatement.

The Medscape report also revealed a higher percentage of female physicians — 48 percent — suffered from symptoms of burnout than their male counterparts — 38 percent. Age may also be a factor. According to the report, about 35 percent of young physicians feel some sort of burnout whereas about half of physicians ages 45 to 54 feel the pinch.

The report also showed that while physicians in all specialties are susceptible to feelings of burnout, some medical specialties tend to show higher rates of burnout:

  • Critical Care — 48%
  • Neurology — 48%
  • Family Medicine — 47%
  • Obstetrics/Gynecology — 46%
  • Internal Medicine — 46%

What is burnout?

The dictionary defines burnout as exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration. But for a physician, burnout is much more…with much more at stake.

Physicians are trained to endure long hours and stressful situations. However, practicing medicine in today’s highly charged political climate filled with intrusive government regulations tends to take a toll with not only the lives of the patient, but quite possibly the physicians, hanging in the balance. There are symptoms of burnout which can easily be missed or overlooked. These include excessive fatigue, insomnia, depression and anxiety. Unfortunately, prolonged exposure to these symptoms may lead one to self-medicate with alcohol or prescription medications…or worse.

Part of the problem is that few in the medical community want to talk about burnout. However, talking about burnout is not only the beginning of a solution but can also save lives.

Fighting burnout begins with a conversation.

Physicians dealing with mental, emotional and physical exhaustion become less able to provide quality care to their patients and find themselves leaving the medical profession altogether…or worse. It’s the “or worse” scenario that worries Dr. Debbie Booher Kolb of Madison.

As president of the Madison County Medical Society, Dr. Kolb wanted to make a difference in the lives of her colleagues. Together with a wellness committee she chairs, they began to formulate a plan to help physicians in their area who felt overwhelmed in their medical practice and to help everyone achieve a better work-life balance. They had no idea the vast support they would have for the Physicians Resource Network Wellness Program.

“My father is a retired radiologist,” Dr. Kolb explained. “I remember being in school and hearing about a friend of my fathers who changed careers. I was mystified by that. I didn’t know that was even an option. I’d never heard of a physician changing careers. It’s not even on your radar once you’re in the medical profession. If you do change careers, it’s to go into pharmaceuticals, medical directorships, or to be a life coach. For physicians, it’s truly a business decision once you leave the profession. It’s sad really to think you could burn out so badly that you leave the profession you loved so much completely behind you.”

But, it’s happening more and more to physicians. With the added pressures of government regulations, such as MACRA, electronic health records, ICD-10, and Medicaid funding, the practice of medicine has become even more complicated today than it was just a decade ago. Unfortunately, these pressures have caused physicians to burnout and not only voluntarily leave the profession of medicine, but also to lose their medical license for inappropriate behavior, or died by suicide.

Dr. Kolb’s mission is to help her colleagues prevent burnout by learning how to cope with its symptoms and finding a better work-life balance. Her mission began in 2014 at the annual meeting of the American Academy of Family Physicians where she first met Dr. Dike Drummond, better known as The Happy MD, and discovered his book, Stop Physician Burnout. Dr. Drummond’s website is www.thehappymd.com.

“This book transcends medicine, and his website is great, too. I was so impressed with his actionable advice. What he taught was good nuts-and-bolts information that made me want to bring him to Huntsville so my colleagues could hear him locally. We’ve had three physician suicides in two
and a half years in Madison County alone. It became more and more apparent that we needed to do something. This is heartbreaking and preventable. All of this coalesced to really be something that we could all get behind.”

And everyone did. Laura Moss, executive director of the Madison County Medical Association, said it wasn’t difficult to get everyone on board with the idea to make the physician wellness initiative a continually evolving priority for Madison County.

“Physician burnout is a trending topic because it’s a huge problem among those in health care. Our hope is that the more we talk about it, and the more solutions such as coaching, counseling and workshops we offer, the more intentional our physicians will become about the decisions they make regarding their own health,” Moss said. “We also hope the more it’s out in the open, the less physicians will feel alone and turn to addiction or worse — suicide. This is not something many physicians were taught about in medical school, and we want to be here to offer ways to help prevent or overcome burnout in a healthy way. MCMS is excited to be focused on taking care of the caregivers and to be giving back to our members in a meaningful way.”

As Dr. Kolb and her colleagues admit, everything begins with a discussion. Little did they know how many lives they were about to touch when they rolled out the first component of the burnout program. The first step was an evening event with Dr. Drummond, which sold out 200 seats and had a waiting list for attendees. Burnout Proof LIVE was a huge success, and it’s just the beginning.

“Burnout transcends specialties, and that’s why our physicians have been so appreciative of this program. After the event with Dr. Drummond, we had people commenting and sharing their stories on social media. That’s what we’re trying to do — effect a paradigm shift in the culture of medicine. We really want to let our colleagues know this is more common than they may realize because physicians just don’t talk about it. We want to start talking about it,” Dr. Kolb said.

How can physicians get help for burnout?

The program in Madison County is an excellent start for awareness and healing, according to Rob Hunt, D.Min., director of the Alabama Physician Health Program, but there’s still more work to be done.

“More programs like the one in Madison County that get people in the medical community talking about burnout is a good start. Unfortunately, there are still so many doctors who don’t understand the warning signs, especially medical students. Female residents are among the biggest burnout populations. I think the key is education. The more they can learn about what burnout is and how to avoid it early in their careers, the better it will be on our physicians and our medical system,” Dr. Hunt said.

APHP is a member benefit for physicians of the Medical Association. It is a confidential clinical resource for physicians, physician assistants, residents and medical students created in 1990 by state law to provide a program for early detection and treatment of medical professionals with problems related to possible impairment due to alcohol, drugs, psychiatric disorders or behavior. About 90 percent of physicians who enter the APHP successfully complete the program and return to their medical practices and see patients.

“Most don’t truly understand exactly what APHP can do until they become part of the program as participants. We are here to help them, and we advocate for them to help them keep their medical licenses. We try to keep or get them healthy and keep them in their medical practice and in the State of Alabama. Our opinion is that a doctor who has gone through APHP as a participant and is being monitored is a safer physician, a better physician, than those who have problems and haven’t gone through our program,” Dr. Hunt explained.

According to Dr. Hunt, most physicians may not even realize they are burning out until the situation becomes substance abuse, disruptive behavior, or other issues that stem from being burned out. It’s these overt signs that APHP can help physicians treat.

“Physicians work as much as 80 or more hours a week easily, and they’ve done that for years and years,” Dr. Hunt said. “Some take medications to cope with that stress. They may not know it, but it gets out of control, and they become addicted. What we see are more middle-aged physicians. Older physicians have learned to cope with that stress. We’ve seen many doctors retire because of EMR, ICD-10 and other government regulations. They just refused to put up with it, so they took that step and closed their practices. It was too much stress. It’s still happening with more and more government regulations that physicians have to navigate. It takes them away from the one thing they trained their entire lives for — medicine.”

Still, if more physicians can learn about what burnout is and how to avoid it early in their careers, the better it will be for our physicians and our medical system.

Could YOU have burnout?

There are specific signs of professional burnout. Ask yourself these questions:

  • Am I overly cynical or critical at work?
  • Do I have to drag myself to work or have trouble getting started once I arrive at work?
  • Am I irritable or impatient with co-workers or patients?
  • Do I lack the energy to be productive at work?
  • Does work consistently satisfy me?
  • Am I disillusioned by the practice of medicine?
  • Have my sleep habits or appetite changed?
  • Do I have headaches, backaches or other physical complaints that don’t subside with rest?
  • Do I use food, drugs or alcohol to feel better or to simply not feel at all?

If you feel you are suffering from symptoms of burnout and would like to get help, please contact the Alabama Physicians Health Program at 1-800-239-6272. APHP is a member benefit of the Medical Association. If you live in Madison County and would like more information about the Physician Wellness program, call (256) 881-7321.

Article written by Lori M. Quiller, APR, Director of Communications, and Mikala McCurry, Communications Assistant.

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Demand for Non-Physician Providers Rose to Make Up for Physician Shortage

Demand for Non-Physician Providers Rose to Make Up for Physician Shortage

The Medical Group Management Association has released its 2018 MGMA DataDive Provider Compensation Survey revealing primary care physicians’ compensation rose by more than 10 percent over the past five years. This increase, which is nearly double that of specialty physicians’ compensation over the same period, is further evidence of the worsening primary care physician shortage in the American health care system.

A closer look at this data shows this rise in compensation is not necessarily tied to an increase in productivity. When broken down by primary care focus, family medicine physicians saw a 12 percent rise in total compensation over the past five years, while their median number of work relative value units (wRVUs) remained flat, increasing by less than one percent. Practices offered more benefits to attract and retain physicians, including higher signing bonuses, continuing medical education stipends, and relocation expense reimbursements.

“MGMA’s latest survey has put strong data behind a concerning trend we’ve seen in the American healthcare system for some time—we are experiencing a real shortage of primary care physicians,” said Dr. Halee Fischer-Wright, President and Chief Executive Officer at MGMA. “Many factors contribute to this problem, chief among them being an increasingly aging population that’s outpacing the supply of chronic care they require. And with a nearly two-fold rise in median compensation for primary care physicians over their specialist counterparts and increased additional incentives, we can now see the premium organizations are placing on primary care physicians’ skills to combat this shortage.”

Further supporting this trend, the new survey identified meaningful growth in compensation for non-physician providers over the past 10 years. Nurse practitioners saw the largest increase over this period with almost 30 percent growth in total compensation. Primary care physician assistants saw the second-largest median rise in total compensation with a 25 percent increase.

“In many communities that we visit, nurse practitioners and other advanced practice providers provide immediate care and same day access. These providers play an important role in today’s health care system. It’s more efficient and less expensive than visiting the emergency room,” said Nick Fabrizio, Principal Consultant at MGMA.

Based on comparative data from over 136,000 providers in over 5,800 organizations, the 2018 MGMA DataDive Provider Compensation is the most comprehensive sample of any physician compensation survey in the United States. The survey represents a variety of practice types including physician-owned, hospital-owned, academic practices, as well as providers from across the nation at small and large practices.

Other highlights from the survey include:

  • Over the past five years, rises in median compensation varied greatly by state. In two states, median total compensation actually decreased for primary care physicians: Alabama (-9 percent) and New York (-3 percent). Many states saw much larger increases in median total compensation compared to the national rate, the top five being Wyoming (41 percent), Maryland (29 percent), Louisiana (27 percent), Missouri (24 percent) and Mississippi (21 percent).
  • Current median total compensation for primary care physicians also varies greatly by state. The District of Columbia is the lowest paying with $205,776 in median total compensation. Nevada is the highest paying state with $309,431 in median total compensation.
  • Over the last five years, looking beyond just nurse practitioners, overall non-physician provider compensation has increased at a rate of 8 percent. Looking at the changes over the past 10 years, that rate has doubled to 17 percent. As non-physician providers have increasingly become patients’ primary care providers over the past 10 years, combined with a subsequent shortage of non-physician providers, compensation rates continue to grow for nurse practitioners and primary care physician assistants.
  • The difference in compensation between the highest-paid state compared to the lowest ranges between $100,000 and almost $270,000 for physicians depending on specialties, and $65,000 for non-physician providers.

The 2018 MGMA DataDive Provider Compensation is the most trusted compensation survey in the U.S., undergoing a rigorous evaluation and inspection. Learn more at www.mgma.com/data.

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What If No One Was On Call [at the Legislature]?

What If No One Was On Call [at the Legislature]?

2018 Recap of the Regular Session of the Alabama Legislature

In times of illness, injury and emergency, patients depend on their physicians. But what if no one was on call? Public health would be in jeopardy.  However, the same holds true for the Legislature. During the 2018 session alone, if the Medical Association had not been on call advocating for you and your patients, unnecessary and costly standards of care would have been written into law, lawsuit opportunities against physicians would have increased and poorly thought out “solutions” to the drug abuse epidemic ─ that could’ve made the problem worse ─ would have become law. Keep reading to find out more.

Moving Medicine Forward

The 2018 Legislative Session is over, but continued success in the legislative arena takes constant vigilance. Click here to download our 2018 Agenda.

If no one was on call…increased state funding for upgrading the Prescription Drug Monitoring Program (PDMP) would not have occurred. Working with the Governor’s Opioid Task Force, the Medical Association proposed increased funding for the PDMP, to allow it to be an effective tool for physicians. As a result, the Task Force made the request its number one recommendation to the Governor and the 2019 budget for the Alabama Department of Public Health (the PDMP administrator) has a $1 million increase for making a long-overdue upgrade to the user-friendliness of the drug database.

If no one was on call…legislation helping veterans at-risk for drug abuse get the care they need and also leverage technology to combat the drug abuse epidemic would not have occurred. Through enactment of SB 200, the prescription information of VA patients will be shared between the VA and non-VA physicians and pharmacists who are outside the VA system, the same kind of information sharing of prescription data that exists for almost all other patients. Passage of SB 200 also establishes a mechanism for vetting requests for release of completely de-identified PDMP information that can be used to spot drug abuse trends and help state officials better allocate resources in combatting this epidemic. The proposals that resulted in the drafting of SB 200 originated with a recommendation from the Governor’s Opioid Task Force, one the Medical Association supported.

If no one was on call…the concerns of physicians regarding the current state of affairs surrounding the Maintenance of Certification program would not have been heard. A formal recommendation from the Medical Association’s MOC Study Committee resulted in the enactment of SJR 62 by Senators Tim Melson, M.D., Larry Stutts, M.D., and the entire Alabama Senate. The resolution was signed by Gov. Kay Ivey. SJR 62 vocalizes Alabama physicians’ frustrations with MOC and urges the American Board of Medical Specialties to honor its commitment to help reduce the burden and cost of MOC. Pursuit of a legislative resolution was just one of several recommendations from the Association’s MOC Study Committee this year.

If no one was on call…the Board of Medical Scholarship Awards could have seen its funding reduced but instead, the program retained its funding level of $1.4 million for 2019. The BMSA grants medical school loans to medical students and accepts as payment for the loan that student’s locating to a rural area to practice medicine. The BMSA is a critical tool for recruiting medical students to commit to practice in rural areas. As well, the economic footprint of every physician is at least $1 million, which improves both community health and local economies.

If no one was on call…Medicaid cuts could have been severe, possibly reducing access for patients within an already fragile system in which less than 20 percent of Alabama physicians participate. The 2019 budget has sufficient funds available for Medicaid without scheduled cuts to physicians. However, increasing Medicaid reimbursements to Medicare levels could further increase access to care for Medicaid patients and remains a Medical Association priority.

Beating Back the Lawsuit Industry

While Alabama’s medical liability laws have fostered fairness in the courtroom and improved the legal climate, each year personal injury attorneys seek to undo parts of the very law that helps keep “jackpot justice” and frivolous suits in check.

If no one was on call…bill language that could have pulled physicians into new lawsuits targeting opioid drug makers and opioid wholesale drug distributors could have been included in the final version of the legislation, whose subject matter was originally limited to placing new criminal penalties on unlawful possession, distribution and trafficking of Fentanyl. After the liability language was added on the House floor, a committee of the House and Senate removed the new cause of action language that could have affected physicians. Additionally, an unsuccessful attempt was made to amend this same bill to give law enforcement the authority to determine what is the unlawful “prescribing” or “dispensing” of prescription drugs. The final bill that passed contained neither of these elements that would have been problematic for physicians.

If no one was on call…physicians and medical practices could have been forced to provide warranty and replacement coverage for “assistive medical devices.” As originally drafted in the bill, the term “assistive medical devices” was broadly defined to include any device that improves a person’s quality of life including those implanted, sold or furnished by physicians and medical practices like joint or cochlear implants, pacemakers, hearing aids, etc. However, the Medical Association successfully sought an amendment to remove physicians, their staff and medical practices from having any new warranty or assistive device replacement responsibility under the act, and the final version doesn’t expand liability on doctors.

If no one was on call…legislation granting nurse practitioners and nurse midwives new signature authority outside of a collaborative practice and for some items prohibited under federal law – thereby significantly expanding liability for collaborating physicians – could have become law. The Medical Association successfully sought to ensure that all new signature authority granted to CRNPs and CNMs was subject to an active collaborative agreement and all additional forms or authorizations granted were consistent with federal law, protecting collaborating physicians from new liability exposure. The final bill was favorably amended with this language.

If no one was on call…physicians could have been held legally responsible for others’ mistakes including individuals following or failing to follow DNR orders on minors. The language of the final bill does not expand liability for physicians.

Protecting Public Health and Access to Quality Care

Every session, various pieces of legislation aimed at improving the health of Alabamians are proposed. At the same time however, many bills are also introduced that endanger public health and safety, like those where the Legislature attempts to set standards for medical care, which force physicians and their staffs to adhere to non-medically established criteria, wasting health care dollars, wasting patients’ and physicians’ time and exposing physicians to new liability concerns.

If no one was on callcollaborative practice in Alabama between nurse practitioners, nurse midwives and physicians could have been abolished. The legislation did not pass. Read the joint statement on the bill from the Medical Association and allied medical specialties here. The bill may return next session.

If no one was on call…legislation to give law enforcement the authority to determine what is the unlawful “prescribing” or “dispensing” of controlled substances (and making violations a Class B Felony) could have become law. The Medical Association sought changes to the bill to require prosecutors to have to prove beyond a reasonable doubt that a physician knowingly or intentionally prescribed controlled substances for other than a legitimate medical purpose and outside the usual course of his or her professional practice, and also to ensure sufficient qualifications for expert witnesses. The sponsor however – arguing that expert witness testimony for prosecuting a physician should not be required – asked the bill not be passed and instead “indefinitely postponed it,” killing the bill for the 2018 session. The bill will return next session.

If no one was on callmarriage and family therapists could have been allowed unprecedented authority to diagnose and treat mental illnesses without restriction. The legislation would also have deleted numerous prohibitions in current law including prescribing drugs, using electroconvulsive therapy, admitting to a hospital and treating inpatients without medical supervision, among other things. The Medical Association offered a substitute bill that (1) ensures all diagnoses and treatment plans made by MFTs are within the MFT treatment context; (2) ensures MFTs cannot practice outside the boundaries of MFT services; (3) prohibits MFTs from practicing medicine; and, (4) ensures all the current prohibitions in state law regarding prescribing of drugs, electroconvulsive therapy and inpatient treatment remain intact. The final bill that is now law contains all of these elements.

If no one was on call…legislation creating a new state board with unprecedented authority over medical imaging could have passed. The legislation would have required x-ray operators, magnetic resonance technologists, nuclear medicine technologists, radiation therapists, radiographers and radiologist assistants to acquire a new license from a new state board, a board granted total control over the scope of practice for each licensee. Quality and access to care concerns abounded with this legislation that many saw as unnecessary. The legislation did not pass, but is likely to return next session.

If no one was on call…proposals to move the PDMP away from the Alabama Department of Public Health and instead under the authority of some other state agency or even to a private non-profit organization could have been successful. In working with the Governor’s Opioid Task Force, the Medical Association stressed the Health Department was the proper home for the PDMP and the Task Force did not recommend that the PDMP be moved elsewhere.

If no one was on call…legislation to place new requirements on and increase civil liability exposure on referring physicians under the Women’s Right to Know Act could have become law. The legislation aimed to provide a woman seeking an abortion with notice that she can change her mind at any time and be entitled to a full refund for not going through with the abortion. The Medical Association sought to fix a longstanding problem that places information-provision requirements on referring physicians under the Women’s Right to Know law. While the Association’s language was adopted, the bill failed to pass. The bill is expected to return next session.

If no one was on call…state law could have been changed to require mandatory PDMP checks on every prescription. Attempts to change this are expected in 2019.

If no one was on call…law enforcement could have been granted unfettered access to the prescriptions records of all Alabamians. Attempts to change this are expected in 2019.

Other Bills of Interest

Rural physician tax credits…legislation to increase rural physician tax credits and thereby increase access to care for rural Alabamians did not pass but will be reintroduced next session.

Infectious Disease Elimination…legislation to establish infectious disease elimination pilot programs to mitigate the spread of certain diseases failed to garner enough support to pass this session.

Data breach notification…relating to consumer protection, is known as the “data breach bill.” In the event of a data breach by a HIPAA-covered entity, as long as the entity follows HIPAA guidelines for data breaches and notifies the attorney general if the breach affects more than 1,000 people, the HIPAA-covered entity is exempt from any penalties. Now, only North Dakota lacks a “data breach” notification statute. The bill was signed by the Governor.

School-based vaccine program…a Senate Joint Resolution urging the State Department of Education and the Alabama Department of Public Health to encourage all schools to participate in a school-based vaccine program passed in 2018. The Medical Association, Alabama Academy of Pediatrics and Alabama Academy of Family Physicians issued a joint statement in opposition to the resolution.

While we remain committed to increasing vaccine rates in Alabama for the very reasons outlined in the “Whereases” of the resolution, we are very concerned about the potential disruption that a widespread school-based program could bring to local practices and the likelihood of detrimental effects of adolescents not visiting the doctor-their medical home–during the critical teen years,” the joint statement from the medical societies reads.

While Gov. Ivey did not sign the resolution, it was ratified under state law without her signature.

Workers comp…legislation to penalize an individual from obtaining workers comp benefits by fraudulent means was introduced this session. The Medical Association successfully sought an amendment to require notice to the physician of termination of a worker’s benefits and to ensure continued payment of claims submitted by a physician until that notice is received. The bill failed to see any action this session.

Genital mutilation…legislation criminalizing the genital mutilation of a minor female was introduced this session. The Medical Association successfully sought an amendment to exclude emergency situations and procedures. The bill died in the Senate during the last days of the session. It is expected to return next year.

If the Medical Association was not on call at the Legislature, countless bills expanding doctors’ liability, placing standards of care into state law, lowering the quality of care provided and diminishing the practice of medicine could have passed. At the same time, positive strides in public health – like new funding for a much-needed PDMP upgrade, better data-sharing with VA facilities and the resolution on MOC – would not have occurred. The Medical Association is Alabama physicians’ greatest resource in advocating for the practice of medicine and the patients they serve.

Questions? For more information contact Niko Corley at ncorley@alamedical.org

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STUDY: Independent Practice Declines Due Partially to EHRs

STUDY: Independent Practice Declines Due Partially to EHRs

A new study conducted by the Trump Administration suggests electronic health records are currently failing at reducing the cost of billing for medical facilities, especially for independent practices.

“Small physicians’ groups and solo providers could not afford to purchase and maintain electronic medical records and comply with government reporting requirements,” the White House report stated. “As a result, hospital mergers are booming, leading to horizontal integration, and large hospitals are buying up physicians’ practices and outpatient service providers to form large, vertically integrated health care networks.”

A study published in the Journal of the American Medical Association shows that billing costs consumed significant chunks of revenue even at a large academic center with a fully implemented EHR system. They represented about 14.5 percent of costs of primary care visits and 13.4 percent of costs for ambulatory surgical procedures. “These findings suggest that significant investments in certified health information technology have not reduced high billing costs in the United States,” the authors state in the report.

Independent physicians have also commented on the burdens of the EHR system. Three out of four physicians believe electronic health records (EHRs) increase practice costs, outweighing any efficiency savings, and seven out of 10 think EHRs reduce their productivity, according to a Deloitte’s recent 2016 Survey of U.S. Physicians.

The results of the survey also indicate physician satisfaction with EHRs varies by practice characteristics. About 70 percent of employed physicians are more likely to think that EHRs support the exchange of clinical information and help improve clinical outcomes compared to 50 percent of independent physicians. The results also revealed 72 percent of independent physicians are more likely to think that EHRs reduce productivity compared to 57 percent of employed physicians. Additionally, 80 percent of independent physicians think that EHRs increase practice costs, compared to 63 percent of employed physicians.

The federal government has financial interests in making it easier for physicians to cope with EHR requirements, according to President Trump’s 2018 Economic Report. As part of its 2018 economic report, released Feb. 21, the White House drew a direct connection between physicians’ struggles to purchase and operate EHR systems and the increase in consolidation among hospitals.

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Alabama Physician Health Program Announces Reorganization

Alabama Physician Health Program Announces Reorganization

The Alabama Physician Health Program, the Medical Association’s confidential resource for physicians and other medical professionals with potentially impairing conditions or illnesses, recently announced a reorganization and new staff to better protect the health, safety and welfare of those it serves.

The APHP provides confidential consultation and support to physicians, physician’s assistants, residents and medical students facing concerns related to alcoholism, substance abuse, physical illness and behavioral or mental health issues. It monitors an average of 280 physicians in Alabama at any given time. These physicians, whether self-referred or mandated, many initially may be hesitant to come forward for help, soon learn the APHP is their best advocate. Now, the APHP has even more staff and physicians available to assist when medical professionals need help.

MEET THE STAFF

Director

Robert C. Hunt, D.Min, ASAM, LPC

Medical Director

Sandra L. Frazier, M.D., FASAM

Associate Medical Directors

James H. Alford, M.D.

Daniel M. Avery, Jr., M.D., FACOG, FACS

Jill Billions, M.D., ABAM, FASAM

APHP Case Manager

Fay McDonnell

APHP Program Coordinator

Caro Louise Jehle

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Study: Range of Opioid Prescribers Play Important Role in Epidemic

Study: Range of Opioid Prescribers Play Important Role in Epidemic

A cross-section of opioid prescribers that typically do not prescribe large volumes of opioids, including primary care physicians, surgeons and non-physician health care providers, frequently prescribe opioids to high-risk patients, according to a new study by researchers at the Johns Hopkins Bloomberg School of Public Health. The findings suggest high-volume prescribers, including “pill mill” doctors, should not be the sole focus of public health efforts to curb the opioid abuse epidemic. The study also found “opioid shoppers,” patients who obtain prescriptions from multiple doctors and pharmacies, are much less common than other high-risk patient groups, suggesting why policy solutions focused on these patients have not yielded larger reductions in opioid overdoses.

“This crisis has been misconstrued as one involving just a small subset of doctors and patients,” said senior author G. Caleb Alexander, M.D., associate professor in the Department of Epidemiology at the Bloomberg School and founding co-Director of the Johns Hopkins Center for Drug Safety and Effectiveness. “Our results underscore the need for targeted interventions aimed at all opioid prescribers, not just high-volume prescribers alone.”

The study, which published on Nov. 29 in Addiction, comes as America’s opioid crisis continues to worsen. Opioids include not only the recreational, poppy-derived drug heroin but also many newer and much more potent synthetic painkillers available by prescription, such as fentanyl and oxycodone. Opioids tend to be highly addictive and when overdosed can stop a user from breathing. Drug overdose deaths in the U.S., which now mostly involve opioids, surged from about 52,000 in 2015 to more than 64,000 in 2016.

Alexander and colleagues have found in previous, smaller-scale studies that a small minority of doctors can account for an inordinately high proportion of opioid prescriptions: just 4 percent of opioid prescribers in Florida, for example, accounted for 40 percent of all opioid prescriptions in that state in 2010.

For this study, he and his team, including first author Hsien-Yen Chang, PhD, an assistant scientist in the Bloomberg School’s Department of Health Policy and Management, examined the relationship between high-volume prescribers and high-risk patients more closely. “While we and others have demonstrated that opioid prescribing tends to be concentrated among a relatively small group of providers, in the current study, we wanted to examine how commonly high-risk patients are prescribed opioids by low-volume prescribers,” Chang said. “We were also interested in whether we could identify systematic differences in the doses and durations prescribed by different groups of doctors caring for the same patients.”

The study covered more than 24 million opioid prescriptions in 2015 by more than 4 million residents of California, Florida, Georgia, Maryland, or Washington, as recorded in a nationwide pharmacy database, QuintilesIMS’ LifeLink LRx.

A key finding was that the high-volume prescribers – those who stayed in the top 5 percent, in terms of total opioid volume, during every quarter of 2015 – were far from being the only prescribers for high-risk patients. Across the five states studied, the remaining, low-volume prescribers accounted for 18 to 56 percent of all opioid prescriptions to high-risk patients, depending on how such patients were defined.

“The point here is that ordinary, low-volume prescribers are routinely coming into contact with high-risk patients, which should be a wake-up call for these prescribers,” Alexander said. “We need to build systems to help prescribers better identify these patients, screen them for opioid use disorders, and improve the quality of their pain management.”

The analysis also revealed “opioid shoppers,” the patient group most commonly thought of as being at high-risk for non-medical use, represent only a small fraction of all opioid users. The researchers defined opioid-shoppers in the study as those receiving prescriptions from more than three prescribers and three pharmacies during any 90-day period. They found this group made up just 0.1 percent of the 4 million patients covered in the study.

“The public health impact of ‘opioid-shoppers’ pales in comparison to that of other high-risk groups we examined,” Alexander said.

The first of these groups, “concomitant users,” were defined as people filling prescriptions for more than 30 days of opioids plus benzodiazepines, a class of tranquilizing drugs that includes Valium and Xanax. Like opioids, benzodiazepines can suppress the nerve signals that sustain breathing. “These two classes of drug interact and enhance each other–they make a dangerous combination,” Alexander said. Nearly one in 10 (9.3 percent) of the opioid prescription users covered in the study were concomitant users.

Chronic high-dose opioid users, comprising 3.7 percent of the total, were another high-risk group that dwarfed the opioid-shopper group. Chronic high-dose users were defined as those filling prescriptions for three months or more for opioids with daily doses equivalent in potency to more than 100 mg of morphine.

The researchers also analyzed prescribers’ prescription patterns and found that, for a group of patients seeing both high- and low-volume prescribers, high-volume prescribers on average prescribed larger doses compared to low-volume prescribers (61 vs. 53 mg morphine equivalents per prescription). Prescriptions from high-volume prescribers also provided about 40 percent more days of supply (22.1 vs. 15.6 days). “Even when the same patients were receiving prescriptions from both low-volume and high-volume prescribers, there was a clear tendency for the high-volume prescribers to provide higher doses for more days of use,” Chang said.

“Our study suggests systematic differences among prescribers. How many opioids you are prescribed, and for how long, appears to depend not only on who you are, but who you see,” Alexander said.

In late October of this year, the Bloomberg School of Public Health and the Clinton Foundation released a comprehensive report, “The Opioid Epidemic: From Evidence to Impact,” that provides evidence-based recommendations to reverse the rising tide of injuries and deaths from prescription opioids. Among its recommendations, the report emphasizes the important role that prescribing guidelines play in improving the safe use of prescription opioids by reducing high-risk use. It also underscores the role of Prescription Drug Monitoring Programs in helping to improve the ability for clinicians to deliver high-quality care for those with pain while reducing the risks associated with unsafe opioid use.

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ProAssurance Establishes the Nation’s First Academic Research Program Dedicated to Physician Wellness

ProAssurance Establishes the Nation’s First Academic Research Program Dedicated to Physician Wellness

BIRMINGHAM – ProAssurance Corporation has announced the establishment of the ProAssurance Endowed Chair for Physician Wellness at the University of Alabama at Birmingham. This academic chair is the first of its kind in the United States and demonstrates ProAssurance’s commitment to its role as a leading advocate for America’s physicians.

The initial $1.5 million gift to the UAB School of Medicine will endow an academic chair and also will support a research team dedicated to addressing health issues unique to physicians as they deal with the stress and pressures associated with providing care to their patients in today’s rapidly evolving health care environment.

As he announced the gift, ProAssurance Chairman and Chief Executive Officer Stan Starnes underscored the importance of the research that will emerge.

“Physicians have always been subject to the high levels of stress from a variety of factors such as society’s expectations for successful outcomes, the threat of litigation and the effect of their professional obligations on the quality of their lives, and their families’ lives. As medicine evolves to address the changing dynamics of health care in America, we must find ways to address these pressures,” Starnes said.

“UAB leadership is committed at the highest level to provide our physicians, residents, fellows and trainees the same type of world-class care they provide for the citizens of Alabama and beyond every day,” said UAB President Ray L. Watts. “This generous investment by ProAssurance to fund a first-of-its-kind academic chair will enable us to recruit an expert in the field of physician wellness who can implement well-designed interventions that enhance our sustainable culture of wellness and provide trainees with tools and resources to manage stress and burnout. The result will be more engaged physicians who can provide the highest-quality care to their patients.”

ProAssurance also expects to provide an additional gift of $500,000 to fund various initiatives in support of physician wellness. The company’s Chief Medical Officer, Hayes V. Whiteside, M.D., said such programs are a logical extension of ProAssurance’s role as a trusted partner with physicians and the nation’s health care community.

“Assisting physicians has always been a high priority for ProAssurance. Now more than ever, we need to ensure that today’s physicians maintain their commitment to our high calling, and that future physicians are equipped to deal with the realities of their vital chosen profession,” Dr. Whiteside said.

“We are fortunate to have some of the best physicians in America right here in Birmingham as part of our School of Medicine, and it is important that we consistently work to provide them an environment that promotes wellness opportunities to help them flourish in their field,” said Selwyn Vickers, M.D., Senior Vice President of Medicine and Dean of UAB’s School of Medicine. “Doctors who take care of themselves are better role models for their patients and for their children, have higher patient satisfaction and safety scores, experience less stress and burnout, and live longer. We are grateful to ProAssurance for their gift, which will greatly enhance our training programs and enable them to create a sustainable culture of wellness.”

In addition to the funds being committed to addressing physician wellness, ProAssurance plans to make an additional financial gift to the UAB School of Nursing to enhance the future of nursing care in Alabama. “Nurses are a crucial part of the care delivery team in our state, and their role will become increasingly important as our healthcare delivery systems expand to meet the demands that will come with the exponential growth of an aging population,” said Starnes.

“Nursing is one of the most versatile — and vital — occupations in the health care workforce, and we strive to train innovative leaders who will transform health care,” said Doreen Harper, Ph.D., Dean and Fay B. Ireland Endowed Chair in UAB’s School of Nursing. “The ever-evolving landscape of health care and the changing profile of the population demand a fundamental shift in the health care system to provide patient-centered care. More nurses will be needed to deliver primary care and community care, ensure seamless care, foster interprofessional collaboration and enable all health professionals to practice to the full extent of their education, training and competencies. This shift will result in reduced errors, increased safety and the highest-quality care for patients. We are delighted and appreciative that ProAssurance is providing this support to help us shape patient-centered health care by preparing recognized nurse leaders who excel as clinicians, researchers and educators in Alabama, nationally and internationally.”

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Medical Association Joins 132 Medical Groups to Oppose H.R. 2276

Medical Association Joins 132 Medical Groups to Oppose H.R. 2276

The inclusion of audiologists in Medicare’s definition of “physician” will create confusion.

In May, legislation (H.R. 2276) was reintroduced in the U.S. House of Representatives that would inappropriately provide audiologists with unlimited direct access to Medicare patients without a physician referral and amend Title XVIII of the Social Security Act to include audiologists in the definition of “physician.” More than 132 medical groups and organizations, including the Medical Association and the Alabama Society of Otolaryngology – Head and Neck Surgeons, strongly urge the U.S. House to oppose H.S. 2276.

Click here to read the letter to the U.S. House Leadership

Click here to read H.R. 2276

While audiologists are valued health professionals who work for and with physicians, they do not possess the medical training necessary to perform the same duties as physicians, nor are they able to provide patients with the medical diagnosis and treatment options they require. And, most audiologists practice in the same areas as M.D./D.O. physicians. So, claims that expanding the services provided by audiologists will somehow mitigate projected M.D./D.O. physician shortages are often unsubstantiated.

Bypassing a physician evaluation and referral can lead to missed diagnoses and inappropriate treatment that could cause lasting, and expensive, harm to patients. The Centers for Medicare and Medicaid Services has maintained a position that physician referral is a “key means by which the Medicare program assures that beneficiaries are receiving medically necessary services, and avoids potential payment for asymptomatic screening tests that are not covered by Medicare ….”

Notwithstanding the patient safety concerns associated with direct access, the inclusion of audiologists in Medicare’s definition of “physician” will create confusion regarding the qualifications and training of various health care providers. And, broadening the term “physician” to include non-physician healthcare providers encroaches on the expert status achieved by M.D./D.O. physicians. Audiologists are not physicians and should not be considered as such under the Medicare program.

Click here to read the letter to the U.S. House Leadership

Click here to read H.R. 2276

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Medicare Releases 2017 Physician Fee Schedule Final Rule

Medicare Releases 2017 Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services released its final rule for its 2017 physician fee schedule payment policies, which updates payment policies and payment rates for services provided under the Medicare Physician Fee Schedule (PFS) starting Jan 1, 2017.

The 1,400-page 2017 final rule discusses changes to a number of new policies that reflect a broader agencywide strategy to enhance quality, spend smarter and improve Americans’ health.

Here are eight changes to note:

CMS will begin gathering data on postoperative visits. The final rule requires reporting of postoperative visits for high-volume/high-cost procedures by a sample of practitioners in practices with 10 or more physicians. Reporting is required for services related to global procedures provided on or after July 1, 2017.

Changes were made to provider and supplier requirements for Medicare Part C. Providers and suppliers will be screened and enrolled in Medicare to contract with a Medicare Advantage organization to provide items and services to those enrolled in Medicare Advantage health plans.

CMS finalized its proposal to expand eligible telehealth services. The additional codes include those for end-stage renal disease-related dialysis, advanced care planning and critical care consultations. The critical care consultations provided via telehealth will use the new Medicare G-codes.

CMS will improve data transparency. Medicare Advantage organizations use a bidding process to apply to participate in the Medicare Advantage program, and the bidding process will reflect the organization’s estimated costs to provide benefits to enrollees. Under the final rule, Medicare Advantage organizations are required to release data associated with these bids on an annual basis. CMS will also require Medicare Advantage organizations and Part D sponsors to release medical loss ratio data on a yearly basis to help beneficiaries make enrollment decisions.

The agency revised the methodology used to calculate geographic practice cost indices. CMS adjusts payments under the physician fee schedule to reflect local differences in practice costs using geographic practice cost indices. The agency will revise the methodology used to calculate GPCIs to increase overall physician fee schedule payments in Puerto Rico. The updates will be phased in over 2017 and 2018.

CMS finalized expansion of the Medicare Diabetes Prevention Program. The 2017 rule finalizes some aspects of the expanded model, but future rulemaking will address payment policies, program safeguards and other issues. CMS expects to begin payment for MDPP services in 2018.

CMS revised the billing codes to more accurately pay for primary care, care management and other cognitive specialties. Among the changes are new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

Physician payment rates will increase by 0.24 percent in 2017. CMS arrived at this increase after accounting for a 0.5 percent increase required by the Medicare Access and CHIP Reauthorization Act and mandated budget neutrality cuts, according to the American Hospital Association.

For more information, please see Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017

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