Jeffrey Bendix

What motivates doctors to provide high-quality care? Most payers and health care institutions assume it’s financial reward. But a new study suggests the answer lies instead in doctors’ relationships with their peers and desire to demonstrate their competence and professionalism to them.

The study’s authors sought to determine whether 

 provide better care to patients referred by primary care physicians (PCPs) with whom they had trained. They analyzed 8,600 patient ratings of nearly 10,000 visits with specialists, comparing ratings of visits with specialists whose training overlapped with the referring PCP in medical school or postgraduate programs with those of patients referred by the same PCP to a specialist who hadn’t trained with the PCP. The visits occurred at a large academic medical institution between 2016 and 2019.

They found that co-training ties between PCPs and specialists were associated with a 9 percentage higher composite patient rating of specialists care as measured on the Care Provider domain of the Press Ganey Medical Practice Survey. That difference is equivalent to improving from median performance to the 91st percentile of quality for specialists.

The authors say the data also suggest that specialists whose training overlapped with the referring PCP were more likely to demonstrate the type of behavior that promotes 

, including showing more concern for the patient, spending more time with them, and engaging in more 

Such behavior, they explain, stems from “peer and audience effects”: specialists know the referring PCP can observe the care they provide by reading their notes and talking to patients. Thus “an audience of familiar peers may elevate physician performance, not only by subjecting it to informed scrutiny but by providing an opportunity to demonstrate commitment to what is valued by the profession.”

Taken together, the authors say, the co-training effects of patient ratings on specialist care are greater than those of other policies and interventions aimed at improving patient experiences such as public reporting, participation in accountable care organizations, health plan effects and hospital characteristics. Consequently, their findings “could have major implications for the organization of care delivery, as they suggest potentially large quality gains from models encouraging peer interactions,” including 

, peer coaching, and multispecialty case discussions.

In addition, they note, strategies aimed at harnessing physician professionalism and the pressure to live up to colleagues’ expectations “could generate gains over many dimensions of care without requiring decision-specific interventions that risk erosion of intrinsic motivation when deployed in aggregate.”

The study, “Physician-Peer Relationships and Patient Experiences With Specialist Care,” was published online January 3 in 

This article was published by our sister publication Medical Economics.

Articles

Patients get better care from specialists who trained with referring PCP, study finds.

Physician peer relationships may hold key to improved care quality

 confirms what many health care practitioners have long suspected: the 

The study found that by the fourth quarter of 2021 burnout rates among doctors, residents and advanced practice clinicians had reached about 60%—“the highest levels ever recorded to our knowledge,” the study’s authors say.

In addition, approximately 40% of respondents to the survey on which the study is based reported at the end of 2021 that they intended to leave their job.

Using a tool known as the Mini Z work-life measure, the authors surveyed 20,627 physicians and advanced practice clinicians at 120 health care systems nationwide between February 2019 and December 2021. Their goals were to measure trends in burnout, 

 and intent to leave before and during the pandemic, and determine factors that might either contribute to or lessen these feelings.

The results showed an overall burnout rate of 49% during the period but significant fluctuations over time. Starting at 45% in early 2019, it declined through the rest of the year then rose briefly at the start of 2020. It subsequently dropped again during the early phases of the pandemic before climbing to 50% at the end of 2020 and continuing to rise to around 60% in the final months of 2021.

Intent to leave increased from 24% in 2019 to more than 40% in late 2021, changing in inverse proportions to reported job satisfaction levels.

Although rates of burnout and intent to leave increased overall during the study period, they varied significantly due to factors such as levels of chaos in the workplace, degree of control over work and feelings of being valued.

For example, in the final quarter of 2021 burnout was 37% among those who felt valued compared to 69% who did not. Similarly, those reporting good control over their work reported burnout levels of 39% versus 75% for those without work control. And levels were 36% among practitioners in calm environments compared with 78% in chaotic environments.

Based on their findings, the authors recommend that health care institutions create a set of key performance indicators to measure work stressors, such as lack of control over workloads and schedules; burnout mitigators, such as teamwork and feelings of being valued; and provider outcomes, such as job satisfaction and intent to leave. This strategy, “could provide measurable and remediable work conditions and outcomes…for protection of the health care team,” and “serve as an early warning system during times of stress to identify challenges and opportunities to improve the work environment.”

The study, “Trends in Clinician Burnout With Associated Mitigating and Aggravating Factors During the COVID-19 Pandemic” was published November 23 in 

Workplace factors play major role in determining job satisfaction, intention to leave.

Physician burnout levels reached new highs in 2021

 has begun charging for some electronic messages its doctors send to patients.

On November 17 the Cleveland Clinic began billing patients’ insurers for messages that typically take more than five minutes to answer and require a doctor’s “medical expertise,” according to 

 on the Clinic’s website. Among these are:

check-ups on care for long-term conditions, and

Message charges will be billed to patients’ insurers. For Medicare beneficiaries, that could result in an out-of-pocket charge of between$3 and $8. Most commercial insurers cover these messages at little or no cost to the patient, the Clinic says. However, patients with plans that don’t cover messages could see charges anywhere between $33 and $50.

“The provider looking at your message might be reviewing the information you sent over and changing part of your treatment plan, or recommending you get a test to learn more. They might need to look at your medical history and do an in-depth review of your records to make sure they give you the best possible advice,” according to the announcement.

The Clinic uses the MyChart electronic health record for its messaging system.

questions about an issue for which the patient was seen within the past seven days,

check-ins that are part of follow-up care after a procedure, or

The Clinic’s announcement comes at a time of financial stress for hospitals and hospitals. The median year-to-date operating margin index for hospitals was -0.1% in September, for a ninth straight month of negative actual operating margins, according to findings in the latest 

Primary care doctors seemingly endorse getting reimbursed for electronic messaging. In a recent 

, 86% said reimbursement for responding to queries through emails, texts, or phone calls was an important tool for enhancing access to care and improving outcomes.

But PatientRightsAdvocate.org, a nonprofit organization advocating price transparency, takes a different view. In 

 on cleveland.com, founder and chairman Cynthia A. Fisher calls the practice “egregious.”

“Billing them [patients] for electronic messages to their providers is just the latest attempt to wring even more blood from the stone,” she said.

Cleveland Clinic begins charging for doctors’ time spent responding to some electronic messages

Five minutes of a doctor’s time could cost patients $50

America’s response to COVID-19 has been hampered by the lack of a national public health system, according to U.S. Department of Health and Human Services Secretary 

, Becerra drew a distinction between the “public health system that is nationwide” the nation now has, and a “national public health system.” With the latter, he said, the person occupying his office would be able during a pandemic to obtain health data quickly from everywhere in the country in order to address the crisis.

“But in our system of public health, we have to beg the 50 states, the territories, the Indian tribal governments, to give us 

 we need to save lives, because they’re not obligated to. It’s unfortunate, and COVID really exposed it,” Becerra said.

Becerra made his remarks as part of a “fireside chat” where he was interviewed on a range of subjects by Ezekiel J. Emanuel, MD, PhD, professor and vice president for global initiatives at the University of Pennsylvania’s Perelman School of Medicine and a venture partner at Oak HC/FT.

Responding to a question about the legislation enabling 

 to negotiate drug prices with pharmaceutical companies, Becerra said in 2023 the Centers for Medicare and Medicaid Services will decide which drugs it wants to focus on and begin negotiations with the manufacturers. The new prices will start taking effect in 2026.

Asked whether CMS would focus more on payment reform in the coming years, Becerra maintained the agency has been seeking alternatives to fee-for-service medicine, but that payers and other industry stakeholders have been aggressive in defending the present system.

“Every time we try to do something in that area we face a lot of litigation, or we face Congress responding to pushback from industry,” he said. He cited the example of lawsuits trying to stop CMS from implanting regulations to eliminate surprise billing, a relatively non-controversial issue.

“The difficulty is we can’t move as quickly as the private sector in a lot of things because we have to follow rules that have been set by Congress or by the courts,” he said, adding that opponets often accuse CMS of being “arbitrary and capricious” whenever it tries to implement change of any kind.

Challenged by Emanuel on the lack of federal research on long COVID, Becerra said, “We want to make sure we don’t leave communities out. Typically with research we go to those folks who are easiest to reach and get tested, and that often leaves out a lot of communities of color and low income. So finding those communities that may never have been approached for clinical trials slows us down.”

He added that Congress has not appropriated enough money for the agency to conduct the research needed to understand the causes of, and find cures for, long COVID.

HHS secretary says federal government will need quicker access to national data to address future health emergencies

 HLTH 2022: Federal COVID response slowed by absence of unified public health system, says Becerra

Primary care practices traditionally have used phone calls to check on the status of patients who’ve recently been discharged from the hospital and address any problems that might cause them to be readmitted. But automatic 

 might be a better way to accomplish those goals, a new study finds.

The study’s authors note that while follow-up phone calls are somewhat effective in reducing unplanned 

, they require a significant time commitment, often go un- answered, and generally reach patients only once.

As an alternative, they designed a 30-day post-discharge 

 using automated texting, with patient needs identified by the messaging platform escalated to practice staff for follow-up. They implemented the program at a university-affiliated primary care practice for five months in 2021.

Then they compared use of acute care resources—defined as emergency department (ED) visits or hospital readmissions-- among recently discharged patients with acute care resource use at a practice with a similar patient population but without the texting intervention. In all, the study included 1,885 patients with 2,617 discharges, including 1,051 from the intervention practice and 1,556 from the control practice.

They found that after implementing the texting program, the odds of acute care resource use within 30 days of discharge were 41% lower than at the practice without the texting program. Moreover, the program integrated easily into the workflow of the practice’s care management team, for whom responding to calls from recently discharged patients was already part of the daily routine.

A further benefit of the program, researchers say, was its positive reception among patients. More than eight in 10 responded to at least one of the introductory text messages, a rate far higher than responses to post-discharge phone calls.

While the authors don’t provide any definitive reasons as to why texting reduces acute care use, they theorize that more frequent check-ins and relative ease of patient-initiated outreach result in earlier identification of potential problems and a greater likelihood that those problems can be handled by the practice rather than in an acute care setting.

Evaluation of an Automated Text Message–Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge” was published online October 26 in 

In study, use of text messages reduced post-discharge ED admissions and hospital readmissions

Texting found more effective than phone calls for hospital discharge follow-ups

 vaccinations at far lower rates than adults, a discrepancy due largely to adult misbeliefs regarding the safety of vaccines generally and 

The study by researchers at the University of Pennsylvania’s Annenberg Public Policy center examines the role of adults’ incorrect beliefs regarding both the dangers of taking COVID-19 vaccines themselves and to recommend them for children. According to the study, as of August 2022 77% of American adults had received the initial primary doses of the vaccine. By contrast, only about 30% of children age 5 to 11 had been vaccinated, even though the Food and Drug Administration had authorized vaccines for that age group in the fall of 2021.

The researchers obtained their data from a survey of 1,600 adults conducted in four waves between April 2021 and January 2022. For purposes of the study they defined 

 as “belief in statements about vaccination that are contrary to the best available evidence as defined by public health authorities.”

 among adults was associated with incorrect beliefs about vaccines generally, such as that they contain toxins like antifreeze, and about specific vaccines such as that MMR vaccine leads to autism. Misbeliefs specific to COVID vaccines included allegations that they cause infertility, alter the recipient’s DNA, are often the cause of allergic reactions and have led to thousands of deaths.

They also found that incorrect beliefs about vaccine safety strongly predicted adult vaccine rates from April to September 2021. Only 40% of those reporting the highest levels of belief in misinformation had received the recommended doses of vaccine by September, compared with 96% of those reporting the lowest levels of belief.

The study showed that misinformation about the safety of vaccines generally, and COVID-19 vaccines in particular, was associated with increased reluctance to recommend vaccinations for children age 5-11.

That was especially the case among households with children under age 18. About 40% of adults in those households said they were “not too likely” or “not at all likely” to recommend the vaccine for children, compared with 29% of all those surveyed. Doubts about recommending the vaccination for children included adults who had themselves been vaccinated, according to the study.

“All of the misconceptions we studied focused in one way or another on the safety of vaccination, and that explains why people’s misbeliefs about vaccinating kids are so highly related to their concerns about vaccines in general,” Dan Romer, Ph.D. the study’s lead author, said in an accompanying news release. “Unfortunately, those concerns weigh even more heavily when adults consider vaccinating children.”

The study, “Misinformation about vaccine safety and uptake of COVID-19 vaccines among adults and 5-11-year-olds in the United States” was published online September 22 in the journal 

Study links discrepancy to adults’ misbeliefs about vaccine safety.