Richard Payerchin

Health care leaders are on notice that physicians, support staff, and patients deserve and expect care settings free from violence.

The U.S. Centers for Medicare & Medicaid Services’ (CMS) 

Center for Clinical Standards and Quality

“Exposure to workplace violence hazards come at a high cost; however, with appropriate controls in place, it can be addressed,” the notice said. “CMS will continue to enforce the regulatory expectations that patient and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare.”

Because of the risk, health care leadership must ensure adequate training, sufficient staffing levels, ongoing assessment of patients and residents for aggressive behaviors, and appropriate care interventions and environment. CMS acknowledged Medicare-certified hospitals already have a regulatory obligation to care for patients in safe settings under current Medicare Hospital Conditions of Participation.

“The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person would consider safe,” with standards ranging from infection control to security that affect emotional and physical health and safety, the memo said.

The Nov. 28 memo sent to state survey agency directors included statistics and examples of workplace violence involving clinicians who face risk factors such as working with people who have a history of aggressive behavior, behavioral issues, or are under the influence of drugs.

An April 2020 facts sheet by the U.S. Bureau of Labor Statistics reported health care workers accounted for 73% of all nonfatal workplace injuries and illnesses due to violence in 2018. That number has grown steadily since tracking began in 2011.

In the latest memo, CMS said hospitals must:

Identify patients at risk for intentional harm to themselves or others.

Identify environmental safety risks, such as ligatures, sharps, access to medications, breakable windows, light fixtures, plastic bags, oxygen tubing, and more.

Take steps to minimize risks, while noting not all strategies are appropriate for all units. For example, strategies for a post-partum unit most likely would not be the same as those in an emergency department.

Implement training for new staff, with ongoing training recommended at least every two years.

Maintain an emergency preparedness plan that accounts for facility risks, community risks, and all hazards.

Workplace violence in hospitals can lead to dire consequences. CMS used examples from facilities that were cited for failing to meet safety obligations:

A nurse in a unit without adequate staffing was sexually assaulted by a behavioral health patient who was stopped by other patients.

A patient died when staff and law enforcement officers performed a takedown that resulted in a custodian holding down the patient on the floor with his knee on the patient’s back.

A patient who was acting out, was shot in a hospital room by police officers when hospital staff failed to assess the patient and de-escalate the situation.

“These cases highlight systemic failures in facilities that place both patients and staff at risk,” the CMS memo said.

The CMS memo is the latest to shine light on the problem and 

 this year began including workplace safety measures among its criteria for evaluating and credentialing hospitals.

 all have condemned aggression toward medical staff. At least two bills have been introduced in Congress to bolster 

 for physicians, nurses and support staff.

This article was published by our sister publication Medical Economics.

Articles

CMS publishes memo to reinforce safety standards for physicians, support staff, and patients.

Hospitals on notice about adding measures to curb growing problems of workplace violence

Flu season is here and that’s good reason for precautions against it as families gather this week for Thanksgiving.

The U.S. Centers for Disease Control and Prevention published its “Weekly U.S. Influenza Surveillance Report” with the statement: “Seasonal influenza activity is elevated across the country,” according to figures up to Nov. 12.

The message to patients is simple: “An 

 is the best way to protect against flu. Vaccination helps prevent infection and can also prevent serious outcomes in people who get vaccinated but still get sick with flu. CDC recommends that everyone ages 6 months and older get a flu vaccine annually. Now is a good time to get vaccinated.”

The American Academy of Family Physicians (AAFP) led a dozen medical groups in a 

 affirming the effectiveness of flu vaccines. Physicians should tell their patients to get vaccinated against the flu and COVID-19.

“A strong recommendation from a trusted clinician is one of the most effective strategies to increase vaccine uptake,” the joint statement said. “We encourage our members to use every interaction with patients as an opportunity to make strong vaccine recommendations, educate and answer questions about prevention and treatment options, encourage vaccination, and where feasible provide vaccination.”

The statement was endorsed by the American Association of Nurse Practitioners, American Academy of Physician Associates, American College of Emergency Physicians, American College of Physicians, American College of Obstetricians and Gynecologists, American Geriatrics Society, American Medical Association, American Osteopathic Association, Council of Medical Specialty Societies, Infectious Diseases Society of America, and AMDA – The Society for Post-Acute and Long-Term Care Medicine.

The U.S. Department of Health and Human Services also has posted an online finder to look up locations of flu and COVID-19 vaccines at 

Across the nation, so far this flu season, there have been at least 4.4 million illnesses, 38,000 hospitalizations, and 2,100 deaths from flu. The most frequently reported viruses were influenza A(H3N2).

Across the nation, so far this flu season, there have been at least 4.4 million illnesses, 38,000 hospitalizations, and 2,100 deaths from flu.

There were 16 states with flu levels rated as “very high:” Alabama, Arkansas, Colorado, Washington, D.C., Georgia, Kentucky, Maryland, Mississippi, New Jersey, New Mexico, North Carolina, South Carolina, Tennessee, Texas, Virginia, and Wyoming. There is a “high” flu rate in Arizona, California, Connecticut, Florida, Illinois, Indiana, Kansas, Louisiana, Nebraska, Nevada, New York, Ohio, Washington, and Puerto Rico.

The flu warning comes as the nation deals with the spread of 

As of the first week of November, it appeared RSV 

 from a spike in the first week of October, but the rate still is higher than it has been for most of the last year, according to other CDC figures.

Avoid touching your face with unwashed hands.

, it appeared new cases, new deaths, were decreasing slightly in the time from September to now, and new hospitalizations were holding steady, according to CDC figures. Among those aged 5 years and older, 11.3% of people, or more than 35.27 million people, had received their updated booster doses.

Tell your patients to get their annual flu vaccines for best protection against illness.

Flu activity ‘elevated’ across more than half the U.S., according to CDC

Primary care physician burnout got worse in developed nations around the world during the COVID-19 pandemic.

 published “Stressed Out and Burned Out: The Global Primary Care Crisis,” a survey of 9,526 physicians in the United States, Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom, from February to September this year.

The survey findings “confirm what many fear could be true: The pandemic is taking an alarming toll on the well-being of our primary care workforce both here in the U.S. and around the world,” Commonwealth Fund President David Blumenthal, MD, MPP, said in an online meeting to discuss the survey.

“Primary care doctors are burned out, stressed, and overworked. Many feel that the pandemic has negatively impacted the quality of care, they are providing,” Blumenthal said. “For decades, we've known that the U.S. and many other countries have faced a shortage of the primary care physicians. And these latest findings suggest that, without interventions, this shortage may soon reach record levels.”

Blumenthal discussed the results with coauthors Munira Z. Gunja, senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations, and Reginald D. Williams II, vice president for International health policy and practice innovations.

In all the countries, a majority of physicians reported increases in workloads since the beginning of the pandemic.

Physicians younger than 55 years were more likely to experience stress, emotional distress, or burnout. In nearly all countries, they were more likely to seek professional help than older doctors.

Physicians experiencing stress, emotional distress, or burnout were more likely to report the patient care they provided was worse than before the pandemic.

At least half of physicians aged 55 years or older said they would stop seeing patients in the next three years. The Commonwealth Fund characterized it as a workforce in crisis, with remaining younger physicians stressed and burned out by their jobs.

Blumenthal and Gunja suggested several solutions:

Greater investment in resources for the well-being of primary care physicians. Those include mental health services.

Increasing Medicare and Medicaid reimbursement for primary care services.

Establishing loan forgiveness to draw more medical students into the field.

They also endorsed the National Academy of Medicine’s National Plan for Health Workforce Well-Being.

The researcher discussed at least two surprises in the findings.

In many instances, the U.S. health care system trails those in other nations in measures. But the new study showed all the health care systems need to figure out how to prioritize the well-being of the primary care workforce if there is hope for a sustainable, high-functioning, high-performing health care system, Gunja said.

Blumenthal said he was surprised the U.S. did not perform worse because in so many respects, the nation’s primary care system is less well-developed and resourced than in other countries.

It could be that primary care physicians in other countries felt more stress than those in the United States because at the height of the pandemic, they were more commonly first points of treatment for COVID-19. In the United States, a lot of patients relied on urgent care and emergency care, and primary care doctors were not as heavily involved in vaccinations as those in other countries, he said.

Commonwealth Fund survey of 10 nations finds primary care in global crisis.

COVID-19 pandemic intensified burnout in primary care physicians around the world

A majority of patients say their physicians’ technology is so bad, they would rather skip an appointment than wade through the scheduling process.

 that fall short of patient expectations, said they report “What patients really want from healthcare.” San Mateo, California-based automation company 

 surveyed 1,005 patients in March this year and published 

“Our survey data shows that when care is difficult to access, many patients simply don’t go to the doctor,” Notable Head of Research Carle Falk said in a 

. “People aren’t skipping doctor visits because they’re confused about test results or worried about a procedure. They’re avoiding medical visits because the appointment-booking process is confusing and takes far too much time and effort.”

The company said legacy digital scheduling programs fall short because they require 

 and schedule intervention. That process creates patient hassles that limit access because health systems have challenges filling their support services jobs.

63% said their provider’s digital tools don’t meet expectations.

61% said they have skipped going to the doctor because of scheduling hassles.

70% of patients tried online scheduling in the past year but were redirected to a phone call.

30% of patients said they have not used digital services in the past year to book appointments, fill out forms, or pay bills.

41% of patients have switched providers due to a poor digital experience.

75% of patients would rather complete intake paperwork online.

Meanwhile, patients reported their waiting times are going up, even as more technology in integrated to streamline visit registration and intake.

Notable recommended a three-step process for physicians, executives, and IT support staff to change their digital interfaces with patients:

Complete a current state assessment on current digital tools and how patients feel about them.

Start by improving patient intake. Notable said “seamless patient intake is non-negotiable for patients.”

Improve patient and caregiver experiences with intelligent automation.

This article was published by our sister publication Medical Economics. 

Tech company surveys patients who say online experience with doctors’ offices is not great.

Use technology to make it easier for patients to schedule appointments

 in the United States, but the 50 states have different per capita spending and rates of increase.

“Varied Health Spending Growth Across US States Was Associated With Incomes, Price Levels, and Medicaid Expansion, 2000-19,” was published in August in 

 per person across the 50 states and Washington, D.C., up to the year before the COVID-19 pandemic.

Researchers aimed to illuminate “changes in health spending during a period with substantial changes in health policy at the state and federal levels,” including the Affordable Care Act (ACA) of 2010 and its provisions for Medicaid expansion after 2014.

“Official state-specific spending estimates that date back to 2014 are not recent enough to enable analyses that consider newer policies or changing state characteristics,” the study said. “In addition, structural, legal, economic, and demographic features vary across US states and types of payers, resulting in substantial variation in health spending across states and payers that is challenging to interpret.”

In 2014, residents of Utah had the lowest annual spending per person at $5,982, while Alaskans spent the most, $11,064 per person per year. Five years later, those states retained their ranks at lowest and highest amounts – $7,250 a year for Utah residents, $14,500 for Alaska residents, according to the analysis.

Primary data came from sources including the U.S. Centers for Medicare & Medicaid Services, the American Hospital Association, the U.S. Commerce Department’s Bureau of Economic Analysis, and the Medical Expenditure Panel Survey.

In 2019, Medicare as a percentage of total health spending ranged from 9% in Alaska, to 30% in Florida.

Medicaid as a percentage of total health spending ranged from 10% of total health spending in South Dakota, to 26% of total health spending in Washington, D.C.

Private insurance as a percentage of total health spending ranged from 25% in West Virginia to 49% in Washington, D.C.

Out-of-pocket payments as a percentage of total health spending ranged from 12% in Washington, D.C., to 42% in Alaska.

Researchers noted the expansion of Medicaid “had a complex relationship with state spending growth.” But emerging trends about the effects of the ACA show increased state and national spending is associated with increased 

, especially for financially disadvantaged patients.

Researchers analyzed spending categories including hospitals, physicians/clinics, nursing facilities, home health, dental, pharmaceutical, and other professional spending categories. In all states, hospitals and physician and clinical services received the most from health care spending per person.

Hospital spending, as a percentage of total health spending, ranged from 35% in New Jersey to 51% in South Dakota.

Physician and clinical services, as a percentage of total health spending, ranged from 16% in Vermont to 30% in Alaska.

There were six non-health-system factors tested to explain variation in health spending per person. They accounted for 77.2% of variation in state per capita health spending from 2000 to 2019:

Behaviors such as physical activity levels and smoking (8%)

For income and regional prices, wealthiest states with the highest prices had the highest estimated per capita spending, while lower income states had lower spending, despite having greater need for health care “because of systematically worse health.”

The researchers noted 22.8% of spending was left unexplained. “This finding calls for a reexamination of possible factors underlying the often piecemeal, state-specific approach to addressing the rising cost and uneven quality of health care,” the study said.

Income, price levels, Medicaid expansion all are factors in state-level analysis.

Health care costs per person vary across 50 states, Washington

Hackers from Iran could pose the next threat to physician and hospital computer networks.

“Iranian Threat Actors & Healthcare” is the latest 

Health Sector Cybersecurity Coordination Center

 (HC3) within the U.S. Department of Health and Human Services. HC3 periodically publishes the briefs and other information about relevant cybersecurity topics to raise awareness of current threats, threat actors, best practices, and tactics to avoid cyberattacks.

Iran is historically a “risk-averse actor,” but online attacks provide “a means to exploit enemy vulnerabilities while minimizing the risk of escalation/retaliation,” according to HC3. Iranian hackers have engaged in website defacement, spear phishing, distributed denial-of-service attacks, theft of personally identifiable information, installation of malware, and social media-driven operations.

In 2021, Iran also signed cooperation agreements that focus on cybersecurity and information and communication technology with Russian, and establishing a 25-year economic and defense collaboration with China, according to HC3. The countries share some common goals including greater censorship.

To avoid cyberattacks, HC3 recommended the measures such as:

User training on spotting and reporting phishing attacks and social engineering that make phony emails appear credible.

Review computer network vulnerabilities and install security patches.

Segment networks to restrict lateral movements by threat actors.

Maintain offline backups of data and regularly test backup and restoration.

Ensure backup data is encrypted, unchangeable, and covers the organization’s entire data infrastructure.

Use strong passwords and multifactor authentication.

Require administrator credentials to install software.

The threat actor “Charming Kitten” is associated with the Islamic Revolutionary Guard Corps (IRGC), according to HC3. That group formed “as an ideological custodian of Iran’s 1979 revolution.” In April 2019, President Donald J. Trump designated it a 

, the first state security agency to receive that designation, according to the 

Charming Kitten, also known as TA453, Cobalt Illusion, Magic Hound, ITG18, Phosphorus, Newscaster, or APT35, has targeted medical researchers, dissidents, diplomats, human rights activists, media, government, military, energy, and telecommunications operations.

The group has used spear phishing, or targeted phony emails that attempt to fool receivers into revealing confidential information. Other tactics include leveraging fake personas and social media platforms to interact with targets and impersonating popular online sites to harvest user credentials, according to HC3, which listed at least eight other hacking handles, including six that use “kitten” in the name.

The IRGC also was the subject of a multinational 

In the United States, Iranian hackers are associated with a thwarted cyberattack on a children’s hospital and a Facebook campaign targeting Americans and Europeans. In that campaign, hackers pretended to work in hospitality, medicine, journalism, nongovernmental organizations, and at airlines, according to HC3.

Things were worse for the government of Albania. That country has the headquarters of the 

, which opposes the ruling regime in Iran, and was the location for the World Summit of Free Iran conference July 23-24, 2022.

The Albanian government faced a two-phase cyberattack that started about 14 months before July 18, 2022, when the “government published a statement announcing that it had to ‘temporarily close access to online public services and other government websites’ due to disruptive cyber activity,” according to HC3.

‘Charming Kitten’ believed to be a front for Islamic Revolutionary Guard Corps, according to HHS’ cybersecurity agency.