24 October 2016

Using CRM and Time-Outs to Focus Hurried OR Teams on Patient Safety

The shift to value-based care and the imminent implementation of MACRA have made efficiency healthcare’s new mantra, and U.S. hospitals and healthcare systems have made operating rooms a high-priority target for optimization. ORs in U.S. hospitals generate about 70% of a hospital’s revenues and operate at a staffed-capacity utilization of 60-70% and OR time costs roughly $80 an hour, so it’s not surprising that metrics like on-time starts, turnover times, same-day cancellations and OR under- and overutilization are under scrutiny. But speed is not the same thing as efficiency, and the faster OR teams work, the greater the risk of something going wrong. 

Dr. Adam Blomberg, National Education Director for Sheridan’s Anesthesiology Division, has long been an advocate of improving efficiency in the OR, calling it a win for “the anesthesiologists, surgeons, nurses, administrators, and most of all, the patients.” But he also worries that the enormous pressure on healthcare providers nationwide to speed up care delivery could eventually result in rushing at the expense of patient safety. An April 2016 analysis commissioned by The Leapfrog Group conservatively estimated that more than 206,000 avoidable deaths in U.S. hospitals each year are caused by medical errors, and those numbers could increase if hospitals’ drive for greater efficiency isn’t paired with an equally strong push to improve patient safety.

In a recent interview with Becker’s ASC Review, Dr. Blomberg urged surgical teams to slow down while speeding up – to work quickly and efficiently but also to remember to “slow down, take a deep breath and still think of the patient first.” He is a strong proponent of crew resource management (CRM) for OR teams. CRM training brings all team members together to learn how to communicate, make decisions and work together as a team both efficiently and effectively. It also standardizes the routine use of checklists and protocols, such as empowering any team member who identifies potential harm to the patient to call a “time-out,” immediately causing the entire team to pause and discuss that member’s safety concern. 

Dr. Blomberg is also Chief of Anesthesiology at Memorial Regional Hospital (MRH) in Hollywood, FL, which is part of the Memorial Healthcare System (MHS) that has experienced significant quality and safety improvements, fewer untoward outcomes and sentinel events, and improved patient experience and satisfaction after implementing CRM.

Dr. Blomberg stresses to his teams the importance of time-outs and has standardized the use of an anesthesia time-out at MRH to make sure the patient and the OR team are on the same page prior to induction of anesthesia. Sheridan’s standard anesthesia time-out is a brief conversation between the anesthesia care team and the circulating nurse to verify that the team has the correct patient, correct side and correct equipment in the OR, and that any necessary vendor or representative for surgical equipment is available prior to induction. The anesthesia time-out can take place after the patient has had pre-op sedation but before he or she is under general anesthesia. Sheridan anesthesiologists also do a surgical time-out with the surgeon as a final double-check prior to incision.

Twelve years after The Joint Commission’s Universal Protocol was introduced, creating widespread adoption of pre-procedure verification, site marking and time-outs, embedding patient safety into surgical teams’ SOP is more important than ever. It’s time we made National Time Out Day redundant.

20 October 2016

Postmastectomy Radiotherapy’s Value for Patients with Early-Stage, Node-Positive Breast Cancer

The American Society of Clinical Oncology (ASCO), the American Society for Radiation Oncology (ASTRO) and the Society of Surgical Oncology (SSO) recently issued a joint clinical practice guideline update for physicians who are treating breast cancer patients who have undergone a mastectomy. The update provides additional considerations to help physicians to determine which patients might benefit from postmastectomy radiotherapy (PMRT) and focuses on the role of PMRT for contemporary patients with early-stage, node-positive breast cancer.

While PMRT is clearly indicated for patients with very high risk of local regional failure, its use is controversial for patients with earlier-stage breast cancer, especially when there are three or fewer positive nodes. The new update focuses on this key area of controversy, stating that there is strong evidence showing that PMRT reduces the risk of breast cancer recurrence, but also providing evidence-based recommendations for the use of PMRT in patients with tumors smaller than 5 cm (T1-2 tumors) and 1 to 3 positive lymph nodes, as well as in patients undergoing neoadjuvant systemic therapy (NAST) and patients with T1-2 tumors and a positive sentinel node biopsy.

The expert panel that developed the updated guideline included representatives from ASCO, ASTRO and SSO. They reviewed relevant literature published between January 2001 and July 2015, including a meta-analysis of 22 clinical trials published in 2014 that provided evidence that PMRT is highly effective at preventing local breast cancer recurrence.

The focused guideline update emphasized that both the absolute benefit of PMRT and the benefit-to-risk ratio can vary substantially from one patient to another, and that doctors should obtain multidisciplinary clinical input and carefully consider factors that could reduce the potential benefit and increase the likelihood of complications before recommending postmastectomy radiation therapy. The panel also concluded that patients must participate fully in the decision-making process, and that their values as to what constitutes sufficient benefit and how to weigh the risk of complications against that benefit in the context of the treating physicians’ best information regarding PMRT must be respected and incorporated into the final choice of treatment.

Stephen B. Edge, MD, co-chair of the expert panel, said “We still don’t have a single, validated formula that can determine who needs PMRT, but we hope that the research evidence summarized in this guideline update will help doctors and patients make more informed decisions.” 

For more detailed information, read “Postmastectomy Radiotherapy: An American Society of Clinical Oncology, American Society for Radiation Oncology, and Society of Surgical Oncology Focused Guideline Update” published in the ASCO’s, ASTRO’s and SSO’s journals, Journal of Clinical Oncology, Practical Radiation Oncology and Annals of Surgical Oncology

This approach reinforces current practices at Sheridan partner Memorial Cancer Institute (MCI) which, like most cancer facilities, faces the complex considerations in deciding whether to recommend PMRT for this subset of patients. Sheridan collaborates with MCI oncologists and surgeons as part of a multi-disciplinary discussion addressing the relative risks and benefits of PMRT for each patient. This team looks at the patient’s entire clinical picture before making a recommendation, and patients are always included in the decision-making process.

19 October 2016

Sheridan’s 2016 Leadership Conference Recognizes Eight Outstanding Clinical Leaders

The annual three-day Sheridan Leadership Conference is Sheridan Leadership Academy’s flagship event. This year’s conference took place Sept. 30-Oct. 2 in Orlando, Florida and was attended by nearly 600 physician and allied health leaders. 


Strengthening the Core

President of Physician Services Robert Coward and CEO Chris Holden provided opening remarks and introduced this year’s conference theme, “Strengthening the Core,” which focused on the key attributes required to succeed as a Sheridan clinical leader. Throughout the conference, each service line held multiple breakout sessions to promote discussion and knowledge sharing of topics related to the conference theme.

New Leadership Academy Programs

This year’s conference also marked the expansion of the Leadership Academy’s programs, whose participants are nominated by their leaders. In addition to the Emerging Leaders Program that began in 2014, the Academy added two new programs this year, the Physician Chiefs Program and the Allied Health Chiefs Program. Each of the three leadership programs kicked off its first course at the conference.

The 2016 Sheridan Leadership Award Winners

One of the highlights of the conference was the awards dinner, which took place on Oct. 1. Eight outstanding Sheridan physicians were honored with 2016 Leadership Awards:

Dr. Mike Adkins, Anesthesia Services Chief of the Year

Michael Adkins has been with Valley Anesthesiology since 1994 – providing cardiac anesthesia services for 13 years, serving as medical director at an outpatient plastic surgery center, and currently is chairman of anesthesia at Banner University Medical Center-Phoenix.

He also has filled important administrative roles during his tenure, including scheduling coordinator, division manager, board member, and principal in the formation and launch of Valley’s Mobile Services Division.

He is a former board member of the Arizona Medical Association and is president-elect of the Arizona Society of Anesthesiologists. He earned his medical degree from the University of Minnesota-Minneapolis, did a surgical internship at the University of Illinois in Chicago and received training in cardiothoracic and neuroanesthesia at Stanford University.


Dr. Joseph Toscano, Emergency Medicine Chief of the Year

Dr. Toscano has been an attending emergency physician at San Ramon Regional Medical Center since 1999 and chief of the department since 2013.

He has extensive experience and expertise in the field. In the early 2000s, he was a partner and corporate medical director for Pinnacle Medical Group, which operated five urgent care clinics in California and Arizona. He lectures frequently at urgent care conferences and is on the board of directors of the Urgent Care Association of America. He has been medical director of San Ramon Regional’s occupational medicine clinic since 1999.

He graduated from Dartmouth College and earned his medical degree from the Duke University School of Medicine. He trained in internal medicine at the naval hospital in San Diego and began practicing emergency medicine during an operational tour of duty with the U.S. Navy in the early 1990s. He moved to California in 1994 and has been an EM physician there ever since.

Dr. Frank Seidelmann, Radiology Chief of the Year

Dr. Frank Seidelmann is co-founder, chairman, and visionary force driving the success of Radisphere. Dr. Seidelmann brings a wealth of experience in radiology with subspecialty expertise in MRI and neuroradiology. He has more than 25 years’ experience in interpreting MRI cases and functions as a consultant on difficult cases for radiologists and clinicians around the country. He has lectured on MRI, both nationally and internationally.

Before venturing into subspecialty teleradiology in 1996, Dr. Seidelmann co-founded a highly successful hospital and outpatient imaging center based radiology group with 20 contracts in the Midwest and central states, at one time employing more than 50 physicians, which was acquired by Med Partners and later became Team Health. He also has owned several diagnostic imaging centers in Ohio and co-founded RIS Logic, a leading radiology software company that targeted diagnostic imaging centers. RIS Logic was later acquired by Merge Healthcare in 2003. Additionally, he has held staff positions at the Cleveland Clinic Foundation and Case Western Reserve University, and has expertise in small joint imaging.

Dr. Mitchell Stern, Women’s and Children’s Chief of the Year

Mitchell Stern, MD joined what was then known as Neonatology Certified in 1987, immediately after completing his Neonatal Fellowship at Babies Hospital (Columbia Presbyterian Medical Center) in New York City. He did his residency, including a chief residency, at Brookdale Hospital Medical Center in Brooklyn, New York. He attended medical school at St. George’s University School of Medicine in Grenada, WI and attended college at Cornell University in Ithaca, New York. 

Dr. Stern joined the staff of Plantation General Hospital in 1987 and became a Director of the unit shortly after Neonatology Certified became a part of Sheridan Healthcare in 1996. Besides being the clinical and administrative leader of the PGH Level III NICU, Dr. Stern has also been the Principal Investigator in several multicentered research projects and has been involved with several committees at both the hospital and HCA Corporate Levels.

Dr. Adam Blomberg, Diamond Award Winner

Adam L. Blomberg, M.D. is the Chief of Anesthesiology for Memorial Regional Hospital in Hollywood, Florida., as well as the National Education Director for Sheridan Healthcare’s Anesthesia Division. He serves on the Anesthesia Quality Committee at Sheridan as the co-chair of the Clinical Education & Best Practice Subcommittee. He has held positions at Memorial on the Physician's Satisfaction Committee and the Multidisciplinary Peer Review Committee as well as the Co-Chair of the Surgical Services Executive Committee.

Dr. Blomberg has had numerous articles published on anesthesia trends and best practices in leading industry publications, such as the Wall Street Journal, CNN Health, ASA Newsletter, Anesthesia Patient Safety Foundation Newsletter, HealthLeaders, Managed Care Outlook and Becker’s Hospital Review. In addition, he has spent more than 15 years as the national speaker for the “Driving Responsibly” campaign.

Dr. Blomberg completed his training at Brigham & Women's Hospital, a teaching affiliate of Harvard Medical School in Boston in the Department of Anesthesiology, Perioperative and Pain Medicine. During his final year of residency, he served as Chief Resident. He is a graduate of the University of Miami School of Medicine in Miami, Florida.

Cindy Houck, CRNA, Platinum Award Winner

Cynthia Houck, CRNA joined Sheridan Healthcare in 1984 after graduating from George Washington University’s Nurse Anesthesiology Program. She has witnessed the growth of Sheridan from a small private anesthesia group to the nation’s largest anesthesia outsourcing provider.

Cynthia has served as the Chief of Allied Health at Memorial Regional Hospital, a 700-bed tertiary care level-one trauma center, since 1993. She has also been the Regional Director of Allied Health, South Florida Region since 2009. Her responsibilities include oversight of all Allied Health in Dade and Broward Counties, 14 hospitals and 6 ambulatory facilities. She was the Clinical Coordinator for SRNAs from FIU from 2006 until 2012.

In addition to her clinical duties, Ms. Houck is also co-chair of the Policy & Procedure Subcommittee for Quality Improvement


Dr. Gary Gomez, Innovation Award Winner

Dr. Gary Gomez has served as chief of anesthesiology at Memorial Hospital Miramar since 2013 and has led several clinical improvement projects. These include enhanced recovery after surgery protocols, PONV prophylaxis tools and i

ntrathecal catheter management protocols. He also was one of three lead physicians to develop the ClearPATh anesthesia patient readiness program and is currently collaborating to develop further clinical pathways as part of Sheridan/AMSURG’s nationwide initiatives.

Dr. Gomez received his medical degree from the University of Florida and is currently enrolled at UF’s executive MBA program. He lives in South Florida with his wife and three children.

Dr. Jonathan Katz, Innovation Award Winner

Dr. Jonathan Katz started with Sheridan eight years ago as a member of the cardiac team at a 227-bed hospital. He was promoted to vice chief a year later and has been a regional medical director for 1.5 years.

Dr. Katz graduated from the University of Pennsylvania School of Dental Medicine and got his medical degree from the University of Connecticut in oral and maxillofacial surgery. He completed his anesthesia residency at the University of Miami, where he served as chief resident and did his cardiothoracic anesthesia fellowship. He also worked as an attending in UM’s cardiac anesthesia subdivision and was assistant program director for the anesthesia residency.



Please join us in congratulating this year’s Sheridan Leadership Award winners.

17 October 2016

Joe DiMaggio Children’s Hospital NICU Joins National Severe Bronchopulmonary Dysplasia Collaborative

The Wasie Neonatal Intensive Care Unit (NICU) at Joe DiMaggio Children's Hospital in Hollywood, Florida, was recently accepted into the national Severe Bronchopulmonary Dysplasia (BPD) Collaborative under the guidance of its medical director, Sheridan physician Bruce Schulman M.D. BPD, a chronic lung disorder of infants and children, is more common in infants with low birth weight and those who require prolonged mechanical ventilation to treat Respiratory Distress Syndrome (RDS). 

The Joe DiMaggio Children’s Hospital NICU, which provides level II and level III neonatal intensive care services, is one of only nine prestigious U.S. medical centers in the BPD Collaborative that have multidisciplinary teams dedicated to optimizing outcomes of infants and children with severe BPD. The other members of the collaborative – all academic medical centers – are:

  • Nationwide Children's Hospital – Ohio State University College of Medicine
  • The Children's Hospital of Philadelphia – Perelman School of Medicine at the University of Pennsylvania
  • The Johns Hopkins Hospital – Johns Hopkins University School of Medicine
  • Women & Infants Hospital of Rhode Island – Warren Alpert Medical School of Brown University
  • Monroe Carell Jr. Children's Hospital at Vanderbilt – Vanderbilt University Medical Center
  • Texas Children's Hospital - Baylor College of Medicine
  • Children's Mercy Kansas City – University of Missouri-Kansas City School of Medicine
  • Children's Hospital Colorado – University of Colorado School of Medicine

The mission of the collaborative is to improve the lifelong outcomes of babies who develop severe BPD by fostering collaboration and innovation in the identification and treatment through the sharing of data, the development and implementation of quality improvement initiatives, as well as fostering research protocols to address the most pressing gaps in our knowledge. 

Sheridan congratulates Dr. Schulman and his Sheridan team along with Joe DiMaggio’s Pediatric Pulmonary Medicine program and Respiratory Therapy services on being accepted into the collaborative and contributing to its important mission.  

13 October 2016

The AMA’s New Tools to Ease MACRA Transition for Physicians

The American Medical Association (AMA) recently unveiled new tools and resources to support physicians through the daunting process of transitioning to CMS’s new Quality Payment Plan (QPP) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These resources include the AMA Payment Model Evaluator, the addition of six new MACRA-specific modules to the AMA STEPS Forward™ collection of practice improvement strategies, and a new ReachMD podcast series titled Inside Medicare’s New Payment System. The AMA developed these new tools to help physicians navigate and prepare for the impending changes to Medicare payment and delivery and to improve their opportunities to succeed when MACRA and the QPP go into effect in 2017.

The AMA Payment Model Evaluator, an online assessment tool to help physicians determine MACRA’s likely impact on their practices, is essentially an interactive decision tree. The physician or medical practice administrator completes a 10-minute questionnaire to provide information about the physician, the practice’s financial structure and its reporting structures. Based on those answers, the tool provides a brief initial assessment of which QPP option might be best, as well as relevant educational and actionable resources. 

AMA STEPS Forward is an interactive, online practice transformation series developed by physicians for physicians. It provides physicians with proven strategies that can improve practice efficiency and help them achieve the Quadruple Aim: better patient experience, better population health, lower overall costs and improved professional satisfaction for providers. The STEPS Forward website includes downloadable educational tools, live event listings, videos and a mechanism for sharing in-depth feedback. 

Currently there are 42 modules in five categories – Patient Care, Workflow and Process, Leading Change, Professional Well-Being, and Technology and Finance – including six new MACRA-specific modules: 

The Inside Medicare’s New Payment System ReachMD podcast series features CMS Acting Administrator Andy Slavitt, AMA President Dr. Andrew Gurman, AMA staff experts and others discussing the upcoming Medicare changes. There have been eight episodes to date:

  • “The Future of Medicare Payment Reform: Perspectives on MACRA with CMS's Andy Slavitt”
  • “Thoughts on Physician Advocacy and Payment Reform with AMA President Andrew Gurman, MD”
  • “The Rise of Specialist-Driven Alternative Payment Models in American Medicine” with Dr. Lawrence Kosinski, founder and Chief Medical Officer for SonarMD
  • “APMs in Cancer Care: The Patient-Centered Oncology Payment Model” with oncologist Dr. Robin Zon
  • “Implementing MACRA: The AMA’s Keys to Advancing Opportunities, Avoiding Pitfalls” with AMA executives Richard Deem and Michael Tutty
  • “Why Participating in Clinical Practice Improvement Activities (CPIA) Matters” with Laura Hoffman, Assistant Director in the Department of Federal Affairs at AMA
  • “Preparing for Quality Reporting: Keys to Keeping Your Practice on Track” with Koryn Rubin, Assistant Director of Federal Affairs at AMA
  • “How an EHR Can Help You Participate in MACRA” with Matt Reid, MS, Senior Health Care IT Consultant at the AMA

Dr. Gerald Maccioli, Sheridan’s Chief Quality Officer, is a member of the AMA’s Physician Satisfaction and Practice Sustainability group that has input into, and partial oversight of, these new tools and resources. Dr. Maccioli says another important reason for creating them was to help bridge physicians’ significant knowledge gap regarding MACRA and QPP. MACRA’s implementation is expected to cause major upheaval at all levels of this country’s healthcare system, yet 50 percent of respondents to Deloitte’s 2016 Survey of U.S. Physicians said they had never heard of MACRA, and another 32 percent said they had heard of the law but were not familiar with its requirements. Only 2 percent said they had in-depth knowledge of this transformative law and its requirements.

“MACRA represents the most significant change to Medicare’s physician payment system in a generation,” said AMA President Dr. Andrew Gurman. “The AMA is helping physicians get started with practical advice presented plainly and clearly, and physicians should begin by logging in today to best understand the changes that are occurring.”

11 October 2016

Giving Patients Bad News: An Eight-Step Approach for Hospital Physicians

Communicating difficult news to patients and their families is one of a physician’s most uncomfortable duties. Physicians’ medical training and professional commitment both focus on curing patients’ conditions and improving or preserving their quality of life. So having to tell a patient that there is nothing more to be done medically can leave a doctor feeling as helpless as the patient and family. Despite knowing intellectually that everything that could have be done to help the patient was done, the doctor still may experience feelings of having failed that patient. And delivering bad news can be even harder for a hospital physician who doesn’t have a longstanding, trusted relationship with the patient.

Effective patient communication is an increasingly essential skill for physicians, yet few have received training or coaching in this area.  As a result, doctors often feel less confident than usual when they need to communicate a negative prognosis to patients and their families, making this difficult task even harder. 

The following framework (adapted in part from an earlier six-step approach published in Family Practice Management) can help hospital physicians communicate difficult news clearly and compassionately.

How to Deliver Bad News to Patients and Their Families

  1. Be as Prepared as Possible. Preparing and planning for a difficult discussion with a hospital patient isn’t always possible, such as in emergency situations. But doing things like finding a quiet, private location for the conversation where there will be no interruptions, arranging for an interpreter, if appropriate, and asking whom the patient wants to be present for the discussion can help keep a very difficult patient experience from being even harder.
  2. Assess the Patient’s Understanding. Asking the patient to share their understanding of their medical condition provides a starting point for the conversation that the physician can build on in Step 4. Consider adding any additional relevant information in the patient’s medical records to provide context for what you are about to tell them. 

  3. Warn That Bad News Is Coming. Don’t tell them what it is yet, just give the patient (and family, if present) a brief heads-up so they can prepare themselves to hear unwanted news.

  4. Deliver It Simply, Clearly and Straightforwardly. Be as brief as possible at this point, especially if the news is likely to be unexpected. Unless your patient is very familiar with the medical terms and jargon related to his or her condition, avoid using them and substitute simpler, more common words that the patient and family can understand more easily. This is especially important when communicating bad news in a language other than the patient’s and/or family members’ native tongue. 

  5. Provide Time and Space to React. After briefly communicating the bad news, stop talking. Give the patient and family members some time and “emotional space” to process what they’ve just heard and then react to it. Observe and listen attentively, quietly, and respectfully as they express their initial reactions – shock, anger, sadness, denial or other emotions. Acknowledge the difficulty of the situation and express your sympathy and compassion. 

  6. Avoid Information Overload. If no questions have been asked yet, ask the patient and family what else they would like to know. As you answer each question, gauge their reactions to help you determine how much detail to provide. Continue monitoring the reactions and body language to help you gauge how much more information, if any, to add once those questions have been answered. Consider preparing a summary of key points and a handout of supplementary information and resources prior to the discussion so the patient and family members can review and refer to them after the discussion, when they have had more time to process the bad news and other information they just received. 

  7. Let Them Know What’s Ahead. Describe the likely progression of the patient’s disease or condition. Explain any choices that may be available in terms of next steps, such as alternative or experimental therapies, chronic pain management techniques or palliative care, if applicable. 

  8. Connect Them to a Care Coordinator or Adviser. To make sure the patient and family don’t feel abandoned during this difficult time, make advance arrangements for them to meet with someone who can help coordinate and connect them with appropriate support resources within and/or outside the hospital. 

Take Care of Yourself, Too

Delivering bad news to anyone, especially someone in your care, is a difficult responsibility. For doctors who must deliver bad news to patients frequently, it can be a significant contributor to physician burnout. Talking about this stressful experience and sharing your thoughts and feelings about it can be extremely helpful, so don’t hesitate to seek advice, counseling or just a sympathetic ear from someone who has been in the same position. 

Find more insights on communicating with patients more effectively in our blog post on Six Physician Communication Strategies to Increase Patient Engagement and Improve Outcomes.

26 September 2016

How to Manage the Burdens of Change on Physicians and Health Care Practitioners

The high cost of U.S. health care continues to grow, thanks to a combination of factors including inefficient care delivery, operational processes and expansion of health care coverage to vulnerable populations. The need to curb these spiraling costs is clear while improving the value of the overall spend. But the shift to value-based care and related health care reform initiatives by both the government and the private sector are burdening health care providers with unreasonably complex, time-consuming and costly record keeping and reporting requirements, thereby encouraging physicians and other practictioners in private or small practices to either join large provider organizations, such as hospitals and physician services providers, or give up practicing medicine altogether. 

Sheridan’s Chief Quality Officer Dr. Gerald Maccioli recently spoke at the 2016 Health:Further Summit about the overwhelming burdens on providers created by current and planned changes to the U.S. health care landscape and offered strategies for managing those burdens.

The Current State of U.S. Health Care


VUCA: “The New Normal” Working Environment for Health Care Providers

Dr. Maccioli began with an overview of the current state of U.S. health care. He used the term VUCA – a concept introduced by the U.S Army War College to describe the volatile, uncertain, complex and ambiguous world environment following the end of the Cold War – to characterize “the new normal” for physicians and other health care providers following the enactment of the Affordable Care Act and now MACRA.

U.S. Health Care Quality

A frequently cited study by the Commonwealth Fund International Working Group on Quality Indicators ranked U.S. health care eleventh globally. But Dr. Maccioli pointed to several other reputable studies and analyses that challenge those findings. The CONCORD study of cancer survival in five continents found that the U.S. ranked first for breast, prostate, and colon cancer survival. The American Enterprise Institute’s report on “The Business of Health” found that when fatal injuries (which are often unrelated to health) are excluded, the U.S. ranking moves up to first place. And researchers at the University of Pennsylvania found that low life expectancy in U.S. is “not likely to be a result of a poorly functioning health care system.” Those metrics indicate that U.S. health care is, in fact, the best in the world.

Health Care Spending Is Outpacing GDP Growth

Since 2009, health care costs in this country have represented more than 17 percent of the gross domestic product (GDP). And despite measures designed to curb those costs, such as the Affordable Care Act, those high costs continue to grow. In 2013, the U.S. spent $2.9 trillion on health care, or $9,225 per capita. And that spend is projected to increase at a rate of 5.7 percent annually – 1.1 percent faster than GDP growth – through 2023, when health care spending will likely reach $5.2 trillion, 19.3 percent of the projected GDP. 

So the primary focus of health care reform should be on increasing efficiency and lowering the cost of care delivery, thereby improving the “value” to both the individual patient and society as a whole.

Three Stakeholders = Three Agendas

Patients are demanding consumer-driven, high-deductible plans with greater pricing transparency. 

Providers are retooling operations to infuse more focus on care management, cost reduction, data utilization, prevention and overall wellness.

Commercial payers are consolidating, becoming more powerful, and both commercial payers and CMS are shifting risk to providers (both downside and upside risk, based on outcomes). Payers are also increasing the number of value-based programs, such as bundled payments, pay-for-performance and shared savings plans. 

The metrics for rating physicians’ quality performance were decided on by federal health officials and insurers. The American Medical Association, various medical groups, patient advocacy organizations and the insurance industry hastily applauded the agreement, glad to finally get broad consensus between CMS and commercial insurers on how physicians would be measured on quality. But that was before more detailed metrics were revealed in the proposed MACRA implementation rules.

Corporate Leaders Adding to Market Pressure

As we discussed in a previous post, 20 major U.S.-based employers with four million covered lives banded together in February 2016 to form the Health Transformation Alliance (HTA). The HTA’s stated goal is “to improve the way corporations provide health care benefits in an effort to create better health care outcomes for their employees. By coming together to share expertise, the companies seek to make the current multilayered supply chain more efficient.” 

These large corporations are pooling their employee health care data to analyze spending and outcomes to identify the best treatment options/providers. HTA is expected to design plans with high-performing providers to deliver high-value care to employees and their families. The group also may eventually use its members’ combined purchasing power to drive down the cost of prescription drugs. 

Complex and Inconsistent Quality Reporting Requirements Have Made Reporting Expensive and Time-Consuming 

Dr. Maccioli highlighted the lack of standardization or alignment in quality reporting requirements. In addition to a panoply of federal requirements in the current CMS quality reporting programs, there are also more than 500 state quality measures in total. There is only 20 percent crossover of those measures among states and medical specialties. In addition, individual insurers and even health organizations often require their own metrics. The cumulative burden of data collection to comply with externally imposed requirements creates an almost unbearable administrative burden for doctors.

Complying with federal and state government and commercial payers’ quality reporting requirements costs U.S. physician practices more than $15.4 billion a year, according to a recent article in Health Affairs that estimates a cost of $40,000 per physician practice annually. 

On average, providers in these practices spend 7.6 hours each week on quality reporting – time that otherwise could have been spent delivering patient care. In addition, staff in these practices spend an average of 15.1 hours per week on documentation and reporting activities. 

Challenges related to the current state of EHR technology, such as poor usability, time-consuming data entry, interference with face-to-face patient care, inability to exchange health information because of interoperability issues, have significantly lowered doctors’ professional satisfaction in recent years. And the cost, complexity and time burdens of complying with changing quality reporting requirements are becoming so high that many doctors can no longer afford to remain in private practice or smaller physician practices.

Heavy Burden on Doctors Leads to Physician Burnout

Dr. Maccioli pointed out that these overwhelming burdens on physicians are major contributors to this country’s physician burnout epidemic. “They are taking the joy out of medicine” and creating debilitating stress levels, he explained. “Physicians are scared. There is so much pressure on them that modern medicine doesn’t prepare them for.” More and more doctors are taking early retirement or even changing professions, exacerbating the increasing physician shortage crisis.  

Seismic Shifts in Health Care Will Multiply the Burdens on Health Care Providers


After reviewing the current state of U.S. health care, Dr. Maccioli addressed the fundamental shifts that are taking place and further increasing the burdens of change on health care providers over the next 8-10 years.

Medicare’s Shift to Value-Based Care

The goal of the CMS is to have 50 percent of all Medicare payments and 90 percent of Medicare fee-for-service payments tied to quality or value by the end of 2018. It is developing and testing new payment models that could put hospital-based physicians at a high risk of commoditization. Yet the stated goals of these programs are encouraging greater integration, coordination among providers and attention to population health, and accelerating the availability of EHR information and interoperability. 

The Medicare.gov website allows consumers to compare data on costs and quality.

Hospital Value-Based Purchasing

CMS’s Hospital Value-Based Purchasing (VBP) Program, which rewards acute-care hospitals for the quality of care they provide to Medicare beneficiaries, is shifting its measurement focus from process measures to outcomes. 

The Macro-Level Market Shift

The revenue mix for providers is shifting rapidly from fee-for-service to value-based reimbursement. 

Dr. Maccioli emphasized that in order to meet value-based goals, both physicians and hospitals will need to reduce utilization among their patient populations, which could potentially reduce their procedure volume and, thus, their revenue.

MACRA Payment Tracks: MIPS and APMs

Dr. Maccioli laid out the two payment tracks for physicians under MACRA – the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) – and presented a quick summary comparison. As of this spring and the proposed implementation rules, these programs are now collectively known as “QPP” (Quality Payment Programs).

Physicians’ revenue will be at risk in one way or another in both payment tracks. However, Dr. Maccioli pointed out, MIPS can serially increase physicians’ compensation without requiring them to assume actuarial risk for care. Because CMS wants to shift more and more risk to providers, it is pushing the use of APMs, including bundled payments, medical homes, and prevention and team-based APMs, by giving participation bonuses to participants in qualified APMs and offering additional incentive bonuses to participants in the most advanced APMs – read those that require providers to assume the most actuarial risk for care. 

Dr. Maccioli also noted that APMs could well become a graveyard for many hospital-based specialties. 

What’s Certain to Change

While there is always the possibility of changes to the proposed MACRA rules between now and the release of the final rule (expected November 1 or thereabouts), the fundamental changes to the CMS payment structure under MACRA are certain. 

  • Providers will need to be on the fee-for-service (FFS) MIPS track or the APM track, and the basic payment framework for each won’t change.
  • Providers in the MIPS track will receive PFS (physician fee schedule) updates, as in the past, plus a new MIPS FFS adjustment (up or down) based on a composite performance score in four weighted performance categories (initially quality, resource use, clinical practice improvement activities and meaningful use of certified EHR technology). During the first six years (2019-2025), providers with composite performance scores in the top 24 percent will also receive an additional positive adjustment factor (capped at 10 percent per eligible provider).
  • For those in the APM track, most physicians and practitioners who participate in APMs will receive favorable scoring under the MIPS clinical practice improvement activities performance category as well as APM-specific rewards. A smaller number of providers participating in the “most advanced”/highest-risk APMs who are determined by CMS to be Qualifying APM Participants (QPs) will receive the most favorable treatment. QPs will not be subject to MIPS and will receive guaranteed five percent lump sum bonus payments for years 2019-2024, and then a higher fee schedule update in 2026 and future years.
  • Annual updates to the PFS will be made starting in 2026 – 0.25 percent for MIPS and 0.75 percent for APMs.
  • The current Medicare quality and value programs, PQRS (Physician Quality Reporting Program), VM (Value-based Payment Modifier) and Medicare EHR Incentive Program (AKA “meaningful use”) will sunset at the end of 2018.

What May Change

CMS has received more than 4000 comment letters since the proposed MACRA implementation rules were put out this spring. As a result of these overwhelmingly negative comments, a September 8, 2016 statement by CMS Acting Administrator Andy Slavitt proposed a possible implementation compromise with potential changes to the MACRA implementation schedule. 

The basics of the proposed compromise pathways are as follows (the options will be fully elucidated in the final rule):

  • Option one: Test the program
    According to Slavitt, as long as you submit some data to the MACRA Quality Payment Program (QPP), including data from after Jan. 1, 2017, you will avoid a negative payment adjustment. This option is intended to ensure that the system is working and that physicians will be prepared for broader participation in the coming years as they learn more.

  • ​Option two: Partial-year reporting
    Physicians can choose to report Quality Payment Program information for a reduced number of days. You could choose a first performance period that begins well after Jan. 1 and your practice could still qualify for an incentive payment.

  • Option three: Full-year reporting
    If your practice is ready to get started on Jan. 1, you can choose to report Quality Payment Program information for the full calendar year. Your first performance period would begin on Jan. 1, and if you submit information for the entire year your practice could qualify for a modest positive payment.

  • Advanced Alternative Payment Model (APM) option
    This option is still available and qualified participants in advanced APMs will be eligible for five percent incentive payments in 2019.

Choosing any of these four options guarantees that you will not receive a negative payment adjustment.

However, Dr. Maccioli emphasized that the actual implementation schedule won’t be known until the Final Implementation Rule is revealed during the first week of November. He said that even if MACRA is delayed, “We need to plan as if MACRA reporting will commence Jan. 1, 2017!“ – a view also shared by The Advisory Board

Quality Reporting Will Become Even More Onerous and Costly

H.R. 2 Medicare Access and CHIP Reauthorization Act, AKA MACRA, requires all providers to prepare for both Merit-Based Incentive Payment System (MIPS) and Alternative Payment Methodology (APM). This requirement means that although MACRA’s new payment structure changes won’t go into effect until 2019, providers should assume that they must move claims-based quality reporting to registry reporting via a qualified clinical data registry (QCDR) by Jan. 1, 2017 – just three months from now – or face significant penalties from CMS.

The need for eligible professionals (EPs) and PQRS group practices to contract with a QCDR to avoid the 2018 PQRS negative payment adjustment will create a significant incremental expense for those providers. And having to prepare and submit quality data to the QCDR in a complex and rigid format will add yet another layer of complexity to quality reporting. 

And between 2017 and 2019, providers will need to collect and submit two different sets of quality data simultaneously – claims-based data and QCDR/registry-based data.

Which Road Should Providers Take?

Beginning in 2019, physicians will be paid according to either a merit-based incentive payment system (MIPS) or through an alternative payment model (APMs). Practices must choose one of those two paths for reimbursement moving forward. Dr. Maccioli advised that even though physicians will be allowed to switch between models from one year to the next, now is the time to select their initial approach and put the appropriate infrastructure into place.

Which is the best choice? It depends. MIPS is closer to the previous fee-for-service model and carries much less risk than participating in APMs. On the other hand, APMs offers the highest maximum reimbursement rate – a guaranteed five percent annual payment increase from CMS over the first six years of the program, within the construct of an ACO… but you have to take whatever the payers define as an APM, which could well change during the course of any year.

Dr. Maccioli said in his opinion, “we have to prepare for MIPS and avoid APMs.”

Preparing for MACRA/QPP’s Impact


Famed British philosopher and logician Bertrand Russell (1872-1970) said, “What men want is not knowledge, but certainty.” Dr. Maccioli promoted the “VUCA Prime” concept introduced by Bob Johansen, Distinguished Fellow at the Institute for the Future, to help organizations reduce the instability associated with the VUCA environment. Johansen asserts that the most effective leaders in the VUCA world counteract volatility, uncertainty, complexity and ambiguity with vision, understanding, clarity and agility. 

Dr. Maccioli outlined the opportunity for entrepreneurs, investors and IT professionals, stressing that provider success in the VUCA world will be contingent on three things:

  • Interoperability - seamless administrative and EHR data integration.
  • Efficient Documentation Tools that reduce the burden on physicians and practitioners and increase their time with patients.
  • Analytic Prowess with Learning Systems – a virtuous cycle of improved patient care and learning.

He reminded attendees that all their “customers” are also in the VUCA world, and that because health care providers are in a high emotion/high cost arena, they need to ask themselves the following questions, based on the October 2015 Harvard Business Review article, “When The Customer Is Stressed”:

  • What about our service is most likely to trigger intense emotions?
  • If customers could magically make one improvement to our service, what would it be?
  • What can we do to make first impressions of our exceptional service?
  • What are the “never phrases” we need to banish?
  • What skills and knowledge are critical to upholding our core purpose?
  • How can we learn from each other to perform at peak levels?

Dr. Maccioli also presented his biases, saying he believes health care administrators and physician leaders should frame any enterprise change or decision with the quadruple aim in mind, i.e., Improving the work life of health care professionals, enhancing the patient experience, improving population health, and reducing costs. He believes that even the best-designed solutions to modern health care issues won’t work “if we don’t improve the work life of physicians.”

Dr. Maccioli also said he firmly adheres to a “just culture” approach – creating an atmosphere of trust, accountability, learning and ongoing improvement. (This is in sync with the Japanese Kaizen philosophy and continuous lean process improvement approach used by Sheridan, which has a dedicated office of Kaizen event facilitators.) He emphasized two key concepts of the “just culture” approach:

  • Humans inevitably make mistakes, and human error and adverse events should be considered outcomes to be measured and monitored with the goal reducing errors and improving system design.
  • Accountability is shared. While everyone is accountable for the quality of their choices, healthcare organizations are accountable for the systems they have designed. Caregivers should be held blameless when errors happened that were not prevented by a systems or processes.

Learn more about what Sheridan is doing now to help physicians reduce the increased quality reporting burdens on physicians under MACRA beginning in January.

19 September 2016

How Physicians, Hospitals and Health Systems Are Dealing With the U.S. Drug Shortage Crisis

The ongoing drug shortage crisis in the U.S. is sending prices for some medications skyrocketing, forcing hospitals and physicians to scramble for alternatives and threatening the safety of patients. These shortages have been causing major problems nationwide for several years, but the causes are complex and not easily fixed, and doctors, hospitals, health systems and acute-care facilities continue to struggle to find effective workarounds.

The number of drugs in short supply in this country has more than tripled in the past decade. Since 2012 when the Food and Drug Administration Safety and Innovation Act (FDASIA) took effect, that number has decreased overall. Yet shortages of drugs commonly used for unscheduled acute care in emergency rooms, intensive care units and other health care facilities have continued to increase in both number and length, with an approximately eight-month median duration. 

Multiple Causes Make Drug Shortages Hard to Fix or Prevent

Most U.S. drug shortages are caused by one or more of the following:

  • Manufacturing / production issues:
    • ​Quality control problems
    • Lack of availability of raw materials
    • Shipping delays
    • Production capacities that either cannot or have not yet ramped up to meet increases in demand
  • Economic issues / business decisions: 
    • ​Market share erosion that causes brand-name drug manufacturers to discontinue production when generic versions enter the market
    • Mergers or acquisitions involving pharmaceutical companies that manufacture the same medication, which typically results in one of those drugs being discontinued for business reasons
    • Discontinuation of older medications in favor of newer, more profitable ones
  • Regulatory issues:
    • Slow FDA approvals for new drugs
    • Pricing constraints tied to federal reimbursements
    • FDA warnings and bans that result in the temporary suspension of production at particular plants or permanent discontinuations of certain products, including commonly used injectable opioids such as morphine and oxycodone and injectable benzodiazepines such as diazepam, midazolam and lorazepam

The Sterile Injectable Drugs Shortage: A Perfect Storm

Sometimes more than one of these factors contributes to the shortage of a particular drug or type of drug. The persistent shortage of sterile injectables – including essential drugs like sterile saline solution and antibiotics that can be effective against superbugs – is the result of a perfect storm of manufacturing, economic and regulatory issues. 

According to a recent article in Forbes, sterile injectable drugs are more expensive to manufacture and notoriously difficult to produce safely, yet because they are subject to federal Medicare and Medicaid reimbursement policies they often have artificially low selling prices. In addition, the FDA’s increased scrutiny of sterile IV fluid manufacturers after particulate matter was found in some products a few years ago has led to recalls, manufacturing delays, and product discontinuations of some sterile injectables. 

Shortages of injectable antibiotics that have been shown to be effective in treating drug-resistant bacteria present another serious challenge, especially in light of the alarming evolution of superbugs. A recent example is this year’s shortage of amikacin sulfate. Amikacin has been shown to be active against certain gram-positive and gram-negative bacteria including Staphylococcus series, Klebsiella series and E. coli, both in vitro and in clinical infections. It also may be the aminoglycoside of choice for serious nosocomial gram-negative infections in areas where resistance to gentamicin or tobramycin is present. Teva Pharmaceuticals is one of the few companies that manufacture amikacin. FDA inspectors who visited Teva’s sterile injectables plant in Hungary in January cited issues with the “current good manufacturing practices” (CGMPs), the regulations for pharmaceutical manufacturing processes and facilities that the FDA enforces. Teva responded by suspending production of all but two of the roughly 200 drugs that were being made there “as a precaution” while it continues to work to resolve those issues to the FDA’s satisfaction. Only amikacin and bleomycin, a cancer treatment drug, continued to be produced at the facility. The FDA subsequently issued an import alert banning all the products made at that plant from the U.S., with the exception of amikacin and bleomycin. But on August 2, Teva announced a voluntary recall of seven lots of amikacin sulfate, citing concerns about the potential presence of glass particulate matter, and as of August 31 the ASHP current drug shortages page includes both amikacin and bleomycin. 

Other manufacturers of sterile injectables have also been forced to halt production at plants outside the U.S. while they address FDA warnings and concerns. Over the past several years, FDA warnings for Hospira plants in Europe, North America, Asia and Australia have caused production stoppages. Pfizer, which acquired Hospira last year, announced a temporary production halt at a plant in India last month after a team of inspectors from four of the world’s leading regulatory agencies, including the FDA, found a number of lapses in good manufacturing practices. 

Price Gouging Exacerbates the Problem

Shortages and discontinuations of drugs that have unique applications or are produced by only one manufacturer have even more severe repercussions. And manufacturer price gouging for these medications is becoming a huge problem. The FDA has been slow to approve new medications that could provide market competition that would drive down prices as well as create alternative options for health care providers during shortages of either drug. 

Another emerging source of price gouging is the misuse of the Orphan Drug Act (ODA). More and more companies are purchasing the rights to existing drugs and submitting them to the FDA for approval as orphan drugs for a different use, to treat diseases that affect fewer than 200,000 people in the U.S. Under ODA, makers of approved orphan drugs get tax credits for half the cost of clinical development (even though companies that purchase the older drugs didn’t pay for the development costs), seven years of exclusivity, and waived fees. So once the FDA approves the drug as an orphan, the drug makers relaunch them under a different name and charge exorbitant prices. 

This trend has a wider impact than it might appear because many of those “orphan” drugs are frequently used off-label to treat much more common conditions, making this practice even more profitable for drug makers. And repeated attempts to curb misuse of the law by ending drugs’ ODA status and benefits once the drug’s target population or sales exceeded a certain threshold have been blocked.

International Politics Have Led to Shortages of Sedatives, Paralytics, Anesthetics and Other Drugs

Commonly used sedatives, paralytics, anesthetics and other drugs that have been used not only by hospitals for medical purposes but also by U.S. correctional facilities as anesthetics for lethal injections have become limited or discontinued. A global campaign by opponents of the death penalty or lethal injections against makers of drugs used for that purpose brought intense pressure to bear, causing many of the manufacturers to stop producing them or severely restrict their distribution. That has left physicians and hospitals scrambling for alternate sources as well as alternative medications.

Hospira, the only U.S. manufacturer of sodium thiopental (Pentothal), is one example. The company had halted production of the drug in 2009 because of manufacturing issues in a North Carolina plant, and after spending two years trying to bring the closed facility into compliance with the FDA CGMPs, had planned to shift production to a plant in Italy. But Hospira was forced to exit the market permanently in 2011 instead after Italian officials said they would not permit the product to be released out of Italy if it could potentially be used for lethal injections.

Some paralytic agents also are no longer being produced for similar reasons, and those that are in production are extremely expensive. There also has been a shortage of agents used to reverse those paralytics, and the prices of those that are available have gone up dramatically; a drug that used to cost roughly $10 per vial can now cost close to $100. 

The FDA’s Dilemma: Balancing Quality and Supply

The FDA is under tremendous fire from two opposing factions: those who argue that the agency’s more zealous inspections and enforcement actions in recent years have been largely responsible for the drug shortage problem, and those who say that zeal must be maintained to protect this country’s patients by ensuring the safety and efficacy of the U.S. drug supply. The FDA’s efforts to straddle this supply/quality tightrope by making exceptions or finding loopholes in the enforcement of its good manufacturing quality practices have often been met with criticism. 

Faced with the sudden shortage of sodium thiopental in 2011, several U.S. states imported untested sodium thiopental for use in lethal injections from a questionable distributor in the U.K., leading the British government to ban the sale of sodium thiopental from the U.K. And a federal appeals court later prohibited the FDA from letting sodium thiopental from foreign suppliers into the country.

In another example, when the agency issued an indefinite ban on a factory belonging to one of China’s leading exporters of pharmaceuticals products last year, the FDA made a highly controversial decision to allow the banned plant to continue exporting about 15 ingredients for use in finished drugs in the U.S., including widely used chemotherapy ingredients doxorubicin and daunorubicin, to avoid possible shortages of key drugs. 

FDA’s Push to Modernize the Pharmaceutical Manufacturing

The FDA has begun working with drug makers to modernize manufacturing methods. This proactive collaboration with drug makers is a new approach “to help the industry adopt scientifically sound, novel technologies to produce quality medicines that are consistently safe and effective — with an eye toward avoiding drug shortages.” The agency says it is encouraging pharmaceutical industry to develop advanced manufacturing technologies, as other industries have done, in order to “create a more robust drug manufacturing process with fewer interruptions. This will minimize product failures and provide greater assurance that the product will consistently deliver the expected clinical performance.” The FDA has established an Emerging Technology Team (ETT) that is providing guidance to drug companies pursuing new technologies, engaging in a dialogue with them early in the technology development process to help identify and resolve scientific issues for new technologies before a drug application is submitted. The agency says it worked closely with the manufacturer of the first-ever 3D printed pill, for epilepsy drug Spritam (levetiracetam), to make the use of 3D printing technology for this application a reality. The agency recently approved the pill, which it says “can disintegrate more rapidly in a patient’s mouth, greatly aiding those who have trouble swallowing.” 

What Can Physicians, Hospitals and Health Systems Do?

Until long-term solutions to the underlying problems causing ongoing drug shortages are agreed upon and implemented, physicians, hospitals and health systems need to continue to develop strategies to acquire vital medications in short supply and workarounds for those that are unavailable. They can also become active in advocacy efforts to help shape effective solutions. 

Use Group Purchasing Organizations (GPOs)

Many hospitals belong to group purchasing organizations (GPOs) that leverage member organizations’ aggregated buying power to drive down prices of products in the health care supply chain, including medications. Pharmaceutical companies often give GPOs preferential treatment when shipping drugs in short supply, so GPO member hospitals acquire more of those medications more quickly than non-member hospitals, exacerbating the shortage of those drugs at those facilities. GPOs have been consolidating to further increase their negotiating power with manufacturers, vendors and distributors. 

There are those who blame drug shortages on these large purchasing groups, notably Physicians Against Drug Shortages, a small, nonprofit advocacy group that has been extremely vocal on this subject. 

Purchase Directly From Pharmaceutical Companies

Many of the drugs that have chronically been in short supply are vital, especially for emergency and acute care. More and more health systems have forged direct relationships with drug makers to procure some of those hard-to-get, critically important products, even though one-off purchases may cost more than buying through a GPO or distributor. GPOs are concerned about the increase in direct purchasing contracts, which threaten the long-standing distribution model and the GPO administrative fees that fund those buying groups.

As a last resort, hospitals and health systems sometimes try to import drugs directly from other countries.

Use or Purchase Alternative Medications

When ready-to-administer doses of a medication are unavailable, the drug may be available in a form that requires the doctor or nurse to fill syringes or make other preparations before administering it to patients.

 In many cases, there are medications with similar uses and effectiveness to drugs in short supply that can be used as temporary alternatives. But they often cost more – sometimes many times more – than the unavailable drug. In some cases, doctors who have no other choice may be forced to use older medications that may not be as effective as the drug of choice or may involve more, or more harmful, side effects.

A team of Yale researchers found that using alternative medications in acute and emergency situations raises the risk of medical error, so it may be advisable to familiarize medical staff with the proper procedures, uses and potential side effects of alternative drugs used in acute and emergent care.  

Use Alternative Techniques

When either paralytic agents are in short supply, or cannot be used because of a shortage of paralytic reversal agents, there are alternative techniques such as regional, spinal or epidural anesthesia or nerve blocks that can be used in some cases to reduce the need for paralytic agents. 

Anticipate Shortages at Health Care Facilities

By monitoring hospital pharmacy inventory and tracking drug usage, hospitals and health systems can sometimes predict which drugs will be in short supply and seek alternative sources in advance. If hospitals know that the price of a drug will be going up or going on shortage, pharmacies can sometimes buy up those drugs far enough in advance to maintain a good supply before the price increases or to tide them over during the anticipated shortage. Sheridan meets with its hospital partners’ pharmacies on a regular basis and helps advise them on the best strategies to address specific current and anticipated shortages.

Participate in Advocacy Efforts to Fix the Problem 

The issues causing ongoing drug shortages are complex and interrelated. Arriving at successful short-term and long-term solutions to the drug shortage crisis will likely require the collective input and collaborative efforts of health care providers and facilities, patients, pharmaceutical companies and local and federal government. More physicians need to be vocal advocates for changes to fix the broken U.S. health care supply chain and rethink current regulatory oversight for the ultimate benefit of patients. 

At the national level, Sheridan’s physician leaders are active in the American Medical Association (AMA), the American Society of Anesthesiologists (ASA), the Society of Critical Care Anesthesiologists (SOCCA) and other organizations that have led physician efforts to deal with the drug shortage issue, including lobbying the federal government (including the FDA) and the pharma industry. Although not all of their advocacy efforts have met with success, some have positively influenced federal policy. For example, the FDA’s 2013 Strategic Plan for Preventing and Mitigating Drug Shortages incorporated several AMA policy elements

Physicians can also participate in these efforts at the state level. Many Sheridan anesthesiologists are extremely active in the Florida Society of Anesthesiologists (FSA), a state component society of the ASA, and a number of those physicians have served on the society’s board of directors. 

14 September 2016

ESPN, Health Care Organizations Threatened by New Lower-Cost, More Flexible Alternatives

A recent article in Hospitals & Health Networks pointed out the striking similarities between the disruption of ESPN and the disruption facing health care organizations. ESPN’s dominant leadership position is being threatened by new lower-cost, more flexible entertainment media alternatives, forcing it to re-think its longstanding, wildly profitable business model. The value-based care imperative is causing equally dramatic disruption to the traditional health care delivery model.

ESPN, which styles itself “The Worldwide Leader in Sports,” has long dominated sports media and in 2012 was valued at $40B, making it the world’s most valuable media property. Since then, however, ESPN has been bleeding subscribers, losing four million between the end of fiscal 2013 and the end of fiscal 2015. Streaming media platforms like Amazon Prime Instant Video, Netflix, Hulu and Sling TV have expanded their content, offering more customizable and lower-priced alternatives to cable and satellite TV subscriptions. To remain competitive, cable companies are offering “skinny bundles” that, for the most part, cut out the highest-price premium channels like ESPN (whose per-subscriber fees cost cable operators four times as much as what they pay for other networks). Streaming media and skinny bundles are cutting into ESPN’s revenue stream, and in order to survive this digital disruption the network needs to reinvent its business model and embrace streaming media. As a tentative first step, ESPN cut a deal with Sling TV to be part of its basic $20/month package. But cannibalizing its enormous cable TV subscription revenue with lower-cost streaming offerings is not a profitable long-term strategy, given the high fixed costs of the exclusive content and commentary that makes sports fans willing to pay.

The move to value-based care is creating similar disruption in the health care market. As with cable’s skinny bundles, narrow networks are excluding high-quality providers that can’t cut their costs enough to meet insurers’ and employers’ low pricing demands. Like ESPN, hospitals also have high fixed expenses that are difficult to trim without negatively affecting care. Medicare reimbursements, a major source of revenue, will be at risk under MACRA. In addition to governmental mandates, health care performance is also under scrutiny from 20 major U.S. corporations including American Express, Coca-Cola and IBM, that formed the Health Transformation Alliance, whose collective data analysis of providers’ cost/quality of care value proposition could also put providers’ revenue at risk. As with entertainment media, new lower-cost, more convenient options are entering the market, such as CVS Minute Clinics, virtual visits and urgent care chains. And telehealth is gaining traction, promising further disruption to long-standing health care business models.

Hospitals and other legacy care organizations need to rethink their long-established business models in order to survive these fundamental disruptions to traditional health care. Like ESPN, they are faced with the fundamental challenge of how to provide higher quality, more convenient services at a lower cost. 

22 August 2016

How Video Laryngoscopy Is Shaping the Future of Anesthesiology

In the new Difficult Airway Management issue of Anesthesiology News, three Sheridan physician leaders who are also prominent anesthesiologists discuss the inexorable shift from fiberoptic intubation and direct laryngoscopy toward video laryngoscopy and how that trend is shaping the future of patient care and the practice of anesthesiology.

Sheridan’s Regional Medical Director Dr. Joseph Loskove, Chief Quality Officer Dr. Gerald Maccioli and National Education Director, Anesthesiology Division Dr. Adam Blomberg say that, although direct fiberoptic intubation has widely been considered a gold standard for anticipated difficult-to-intubate (DTI) patients, a lack of consensus among national anesthesia societies on what constitutes best practice in specific situations brings into question whether a universally applicable gold standard for difficult airway management can, or should, exist.

This lack of agreement on clinical best practices makes the inherently difficult job of intubating DTI patients even harder. Further complicating clinical decisions about difficult airway management practices is that as video laryngoscopy becomes the primarily modality of choice, clinicians who intubate patients only occasionally or who have less experience with fiberoptic intubation and direct laryngoscopy become less comfortable using them.

Drs. Loskove, Maccioli and Blomberg emphasize the need to provide anesthesiologists and other clinicians who might need to intubate DTI patients with better and more consistent guidance that helps them make good judgment calls about the optimal modality for a specific application or case, as well as more helpful guidance on when it might be advisable to change to an alternative modality in the event of complications. The authors also stress the importance of helping anesthesiologists maintain or develop their level of comfort using conventional laryngoscopes, so that they maintain a complete and comprehensive set of laryngoscopy modalities in their DTI tool kits and are comfortable switching from video laryngoscopy to fiberoptic intubation or direct laryngoscopy if the technology fails them.

The article concludes with a discussion of the importance of optimizing and implementing system-wide protocols, such as the extremely successful difficult-to-intubate protocol that Dr. Loskove installed throughout the Memorial Healthcare System (MHS).

Read more about the perspectives of these renowned anesthesiologists and physician leaders in their Anesthesiology News article, The Shift Toward Video Laryngoscopy: The Good, the Bad, and the Future.