Bob Gatty

A new report by the National Academy of Medicine urges action by government, educational institutions, and health care organizations to address the causes of physician burnout, which is experienced by up to one-half of clinicians in the U.S. and threatens patient care.

A combination of cumbersome and sometimes seemingly unnecessary rules and payment procedures, plus staff shortages and pressure to enter the age of electronic medical records, is causing emotional exhaustion, detachment, and a low sense of personal accomplishment, the report says.

“Studies estimate that between 35% and 54% of U.S. nurses and physicians have substantial symptoms of burnout, and the range for medical students and residents is between 45% and 60%. There are indications that burnout is a problem among all clinical disciplines and across care settings,” the report states.

“The high rates of burnout reported among U.S. clinicians and learners is a strong signal that the nation’s health care system is failing to achieve its aims for system-wide improvement.”

“Burnout is real,” said AUA President John H. Lynch, MD. “It impacts the entire health care system, and exacerbates already-existing work force shortages in many specialties, including urology.”

Dr. Lynch said the report reflects the findings of the AUA Census, which reported burnout rates for urologists as being high, with more than one-third experiencing symptoms.

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“Addressing causes of burnout is a priority for the AUA,” said Dr. Lynch. The AUA endorses the six goals outlined in the report:

Health care executives should commit to, and be accountable for, creating a work environment that promotes high-quality care, job satisfaction, and social support, the report says. It recommends that health care organizations create and maintain an executive leadership role dedicated to clinician well-being.

Addressing burnout in training and at early career stages.

 Schools of health professions (including medical schools, nursing schools, schools of pharmacy, and others) should alleviate major sources of stress by monitoring workload (including preparation for licensure examinations and required training activities), implementing pass-fail grading, improving access to scholarships and affordable loans, and building new loan repayment systems.

Reducing tasks that do not improve patient care. 

Federal agencies, state legislatures, and other standard-setting entities should identify and address the sources of clinician burnout related to laws, regulations, and policies, eliminating those that contribute little or no value to patient care. They should specifically evaluate regulations and standards related to payment, health information technology, quality measurement and reporting, and professional and legal requirements for licensure.

Improving usability and relevance of health information technology. 

Health information technology (IT), including electronic health records, should be as user-friendly and easy to operate as possible to reduce burnout. Health IT vendors and health care organizations should deploy technologies to reduce documentation demands and automate non-essential tasks. In addition, federal policymakers and private sector health IT companies should collaborate to develop the infrastructure and processes that enable shared decision-making between clinicians and patients.

Reducing stigma and improving recovery services

. Many clinicians do not report burnout because they fear the potential consequences, including loss of licensure. In order to eliminate the stigma of getting help and to promote recovery and well-being, state legislative bodies should facilitate access to employee assistance programs, peer support programs, and mental health providers without the information being admissible in malpractice litigation.

Creating a national research agenda on clinician well-being. 

By the end of 2020, federal agencies-including the Agency for Healthcare Research and Quality, the National Institute for Occupational Safety and Health, the Health Resources and Services Administration, and the U.S. Department of Veterans Affairs-should develop a coordinated research agenda on clinician burnout, according to the report.

The report points out that mounting system pressures have contributed to an imbalance in which the demands of the clinician’s job are greater than the resources available to complete the job effectively.

All of that is intensified by the increasing push for performance improvement, technology that hinders rather than supports patient care, changing professional and societal expectations, and policies that are insufficiently aligned with professional values or the goal of better patient care, the report concludes.

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Overwhelming job demands and insufficient job resources cause physical, psychological, and emotional stress, including burnout-a workplace syndrome that is characterized by high emotional exhaustion, high depersonalization (ie, cynicism), and a low sense of personal accomplishment from work, the report observes.

“The work system-including the physical environment, the technologies in use, and how care team members interact with each other-deeply influences clinicians’ professional well-being,” said Pascale Carayon, PhD, co-chair of the committee that wrote the report and professor and director of the Wisconsin Institute for Healthcare Systems Engineering at the University of Wisconsin, Madison. “To provide the best patient care possible, health care organizations must create a work environment that fosters clinicians’ safety, health, and sense of fulfillment.”

“For many clinicians, developing real relationships with patients is what attracted us to health care in the first place, but administrative tasks often take us away from patient care,” said Christine Cassel, MD, senior adviser on strategy and policy and professor of medicine at the University of California, San Francisco and committee co-chair. “With this report, we have a real opportunity to change the culture of health care delivery and help restore clinicians’ well-being and joy in medicine.”

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Report urges action on physician burnout

A new study by the Partnership for Health Analytic Research (PHAR) appears to bolster arguments by independent physicians and those who operate outpatient clinics that they are at a substantial financial disadvantage against hospitals when it comes retaining profits from the administration of injectable and infused drugs.

The analysis, completed by Jesse D. Ortendahl, MS, and Katalin Bognar, PhD, finds that hospitals retained 91% of profits from physician-administered medicines while serving 53% of patients receiving physician-administered medicines. Independent practices retained just 9% while serving 47% of patients.

Advocates work toward Office of Men’s Health

PHAR, which counts a substantial number of drug manufacturers as clients, said its research also suggests that hospitals are earning more from administering medicines than the manufacturers who created them. For every $100 spent on physician-administered medicines in the hospital outpatient setting, the hospital retains $58, while the manufacturer receives less than $42, the report said.

Efforts to obtain comments from the American Hospital Association (AHA) and the Federation of American Hospitals were unsuccessful. However, in its 2019 Advocacy Agenda, AHA stresses the importance of “establishing fair and sustainable drug pricing and reimbursement.” AHA also calls on Congress to “restore vital funding and prevent further cuts to the 340B drug savings program, which allows hospitals to provide programs that improve access to care in their communities.”

Dr. Holton: Study emphasizes unfair disadvantage

Mara R. Holton, MD, CEO/president of Anne Arundel Urology in Annapolis, MD, and vice chair of health policy at LUGPA, said the PHAR study emphasizes what LUGPA contends is an unfair and anticompetitive marketplace disadvantage for physician-operated clinics.

“How can we compete with these large health systems that have such extraordinary advantages?”

“Fundamentally, our concerns are the preservation of the independent practice setting as a cornerstone of the American health care system, representing a unique and integral venue for the delivery of high-quality and cost-efficient health care services,” Dr. Holton told 

“How can we compete with these large health systems that have such extraordinary advantages?” she asked, pointing to the huge disparity in profits from physician-administered medicines. “These are identically credentialed providers, and there is no difference in the patient’s experience, except for convenience.”

That’s why, she says, LUGPA and other organizations have tried to convince Congress and the Centers for Medicare & Medicaid Services (CMS) to “level the playing field.” That would include reforming the 340B Drug Pricing Program, which Dr. Holton contends “creates a slush fund of cash that hospitals have been able to use to acquire physicians’ practices and increase vertical consolidation, thus driving up cost.”

In addition, said Dr. Holton, “There are several statutory and regulatory provisions that promote continued hospital consolidation, escalate the rise in health care costs, and imperil the survival of independent practices.”

• disproportionate reimbursement for the same services performed by hospital outpatient departments (site non-neutrality)

• benefits both in lower acquisition cost for pharmacy (340B for example) and much higher reimbursement for the same drug administration, as shown in the PHAR study

• reform of fraud and abuse laws (federal Stark physician self-referral law and the federal Anti-Kickback Statute).

LUGPA joined with the AUA, American Association of Clinical Urologists, and several other organizations to sign a letter in April in support of H.R. 2282 and its companion in the Senate, S.966, “The Medicare Care Coordination Improvement Act of 2019,” which would clear the way for physicians to participate and succeed in APMs without running afoul of the Stark law.

The letter contends that the Stark law prohibits payment arrangements that consider the volume or value of referrals or other business generated by the parties.

“Congress recognized the Stark Law was a barrier to care coordination long ago when it authorized the Secretary at the Department of Health and Human Services (HHS) to waive the self-referral and anti-kickback prohibitions for Accountable Care Organizations,” the letter adds. “MACRA’s full potential can only be achieved by modernizing this law for physician-led APMs as well.”

CMS proposed rule shows room for improvement

H.R. 2282 would remove some of these barriers by:

• providing HHS the same authority to waive Stark provisions and associated fraud and abuse laws for physicians seeking to develop and operate APMs as was provided to accountable care organizations in the Affordable Care Act

• removing the “volume or value” prohibition in the Stark law so physician practices can incentivize physicians to abide by best practices and succeed in value-based alternative payment models.

Trump admin interested in improving process

Meanwhile, Dr. Holton said the Trump administration has shown “a lot of interest” in improving the regulatory process regarding Stark so practices can participate in those models.

“CMS has been very forward thinking about recognizing that outpatient physician care can be provided at significantly less cost and has done a number of things to help,” Dr. Holton said. But much more needs to be done, she said, including congressional reform of Stark.

“In some cases, practices are able to own surgery centers, in some, they are not. But that speaks to the fact that on the regulatory side, CMS has been helpful in recognizing that independent practices offer a meaningful way to reduce health care costs overall. It is a nod, not a bow.”

She said LUGPA fully supports CMS’ Sept. 26 announcement of its Omnibus Burden Reduction (Conditions of Participation) final rule, which the agency says “strengthens patient safety by removing unnecessary, obsolete, or excessively burdensome health regulations on hospitals and other health care providers.”

CMS says it will save providers an estimated 41.4 million hours previously spent on paperwork annually, with a projected savings of $8 billion over 10 years.

A new study by the Partnership for Health Analytic Research appears to bolster arguments by independent physicians and those who operate outpatient clinics that they are at a substantial financial disadvantage against hospitals when it comes retaining profits from the administration of injectable and infused drugs.

Urology groups: 340B program reform needed

A renewed effort to establish a new Office of Men’s Health, which would improve coordination of initiatives throughout the federal government and improve education, awareness, and screening programs to improve men’s health, is now underway in Washington.

Led by the nonprofit Men’s Health Network (MHN), the initiative seeks to establish a new entity within the U.S. Department of Health and Human Services (HHS) to provide education and awareness of men’s unique health needs, including diseases such as testicular and prostate cancer.

“Establishing an Office of Men’s Health is vital to the support and promotion of messaging to men and their families,” said Ana Fadich-Tomsic, MHN’s vice president.

“We at MHN strive to provide free educational events and materials to communities across the country, so that every man has a fighting chance against prostate cancer,” she said. “Our outreach efforts could be greatly amplified with an established Office of Men’s Health to disseminate the information and provide recommendations for men to follow throughout the year, including Men’s Health Month and other awareness periods, similar to how the Office of Women’s Health supports Women’s Health Week and Breast Cancer Awareness Month.”

MHN seeks support of congressional caucus

Establishing an Office of Men’s Health within the federal government requires Congress to pass authorizing legislation, so Fadich-Tomsic said MHN has drafted a proposed bill and is seeking the support of the Congressional Men’s Health Caucus, co-chaired by Reps. Donald M. Payne, Jr. (D-NJ) and Markwayne Mullin (R-OK).

A spokesperson for Payne said his boss was “working with” MHN, but that the prospects for the enabling legislation needed to establish an Office of Men’s Health are unknown. Similar efforts have been made in previous years but have been unsuccessful. Both Payne and Mullin have been active supporters of MHN, participating in the organization’s annual workout events on Capitol Hill.

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“We’ve been working with the Men’s Health Caucus to see if they’re interested in being a sponsor of the legislation,” Fadich-Tomsic said. “They have a lot going on, but we’re hopeful because we’ve been getting good responses.”

Representatives of MHN have been in touch with officials at HHS and the Centers for Medicare & Medicaid Services and have been told that they support the initiative if Congress approves the legislation.

“We’ve talked to all the different agencies, but not the White House as yet,” Fadich-Tomsic said, explaining that it is difficult to know who, exactly, to contact there. “So, we haven’t been able to sit down with the Trump administration. With the Obama administration, we had a dialogue on men’s health that we hosted. We brought in people from corporations and speakers to discuss why focusing on men’s health is important, how it benefits women’s health, and family health overall.”

In addition, she said MHN has contacted the governors of all 50 states, mayors of major cities, and other legislators urging them to support the legislative initiative.

“We work closely with the American Urological Association, and they participated in briefings with us,” she said. “They provided us with speakers and every year I attend their annual meeting and sit on their panels. Also, I work with the Urology Care Foundation, as well as LUGPA and the American Society for Men’s Health.”

Men’s health a concern for women, govt.

The draft legislation, which has yet to be introduced, is called the “Men’s Health Awareness and Improvement Act.” Among key points made in the bill:

• Risks to the health and well-being of men and their families are on the rise because of a lack of education on, awareness of, and pursuit of preventive screening and care.

• It is a health crisis that is also a concern for women regarding their fathers, husbands, sons, and brothers.

• The U.S. Census Bureau predicts that in 2020, 45% of people age 65 and over will be men and 55% will be women, a marked decline in the male population.

• Men’s health is a concern to government, which must absorb the high costs of premature death and disability, including the cost of caring for dependents.

• Educating men, their families, and health care providers about the importance of early detection of men’s health issues can result in reducing mortality rates and improving health and the nation’s overall economic well-being.

• Of concern is the physical, mental, and emotional well-being of military men (and women) returning from war zones and the country’s veterans.

• According to the National Cancer Institute, cancer mortality is markedly higher among men than women.

• Prostate cancer is the most frequently diagnosed cancer among men, with nearly 165,000 diagnosed this year alone and almost 30,000 facing death.

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According to the bill, the Office of Men’s Health would be headed by a director appointed by the HHS secretary. It would conduct, support, coordinate, and promote programs and activities to improve the state of men’s health in the U.S. and consult with HHS offices and agencies to coordinate public awareness, education, and screening programs and activities relating to men’s health. Emphasis would be on colorectal and prostate cancer, diabetes, cholesterol, and mental health screening programs for men identified as being at increased risk of developing such conditions and diseases.

Establishing the new Office of Men’s Health would build upon the success of the Office of Women’s Health, according to Fadich-Tomsic.

“We’re trying to show this would not take away from Office of Women’s Health,” she explained. “We’re trying to make it an even playing field.” 

Advocates work toward Office of Men’s Health 

Willie Underwood, III, MD, MSc, MPH, the Buffalo, NY urologist elected to the American Medical Association’s Board of Trustees in June, believes physicians must step up and help influence governmental decisions designed to improve and expand health care for all Americans.

“We know our health care system is broken for our patients and for us (as physicians). Urologists have to have a place at the table. We’re all in this boat together and we must be a part of the process moving forward,” Dr. Underwood said in an interview with Urology Times.

With the current political debate raging over Democratic presidential candidate proposals for some version of Medicare for All versus strengthening the Affordable Care Act (ACA) and continuing Republican efforts to scrub the ACA, Dr. Underwood is convinced that the overall outcome must be providing universal coverage for everyone.

“As physicians, we must be part of that conversation,” he said, “because we can’t do what we do best without our patients having access to coverage.”

Medicare for All would ‘destabilize coverage’

Dr. Underwood expressed the AMA’s policy position that enacting a Medicare for All plan would be fraught with problems, reducing coverage options, eliminating patient freedom of choice, injecting partisan politics into coverage policy, threatening access to mental health and contraceptive coverage, and more.

“It would destabilize coverage for 150 million people who already have insurance coverage. Health care is 20% of our economy, and Medicare for All would destabilize that,” he said, noting that such a plan would really not be a panacea, considering that millions of Medicare patients also pay for Part D drug coverage and supplemental plans to cover the gaps left by the health care plan for the elderly.

“We need to make sure that the health system works for the rich and the poor,” he stressed. “Your economic status, what you are born into, should not limit your quality of life. Poor black people have less than 10 to 12 years of life expectancy than whites, and it looks like Hispanics will be the same. That is wrong and somewhat criminal in a society that is as wealthy as ours.”

These issues must be addressed as health care policy is developed for the future.

“You’re only as strong as your weakest link,” he said, noting that in Buffalo there are five zip codes, dominated by African-American residents, where the mortality rate from disease is 300% higher than the rest of Erie County and the state of New York.

“You have a medical school, a law school, a school of public health, a dental school. Yet there is no strategic plan to fix this,” Dr. Underwood said. “These are some of the things we have to address, and I don’t think Medicare for All will fix that. We can send people to the moon and probes to Mars. We can do whatever we want to do. So, we can fix that. I think if we do, we will be a stronger nation for it.”


	There are other key issues of particular concern to Dr. Underwood, such as physician burnout, which he said increased by some 40% in 2017, with some 300 to 400 physicians committing suicide last year.

“A lot of it has to do with the way our system doesn’t work for us,” he said.

Some of that involves such practice issues as requirements for electronic medical records and increased paperwork requirements that result in 2 hours of paperwork compared to 1 hour of patient care.

“Urologists are cleaning up records at night,” he said. “We are working harder with less reimbursement. Private practices are being run out of business and urologists are being forced into either large practice groups or hospital health systems. Many who are working in health systems are finding themselves less satisfied with their positions, in contracts they didn’t really understand, and are having to move out of the area if they break away from the hospital system.”

Many smaller practices and groups are in trouble, said Dr. Underwood, because they are unable to create the infrastructure necessary, such as electronic medical records technology, “and all the things that they need to pay for performance indicators, etc., so that increases the burden, and they find themselves in the position where they have to get out of the business, sell their practice to a hospital, or join a large urology group if one is in their area.”

Dr. Underwood said efforts by the AMA that helped result in proposed mergers between Aetna and Humana and Cigna and Anthem Health failing to be finalized saved physicians upwards of $500 million a year because “they would have had a monopoly and would have imposed contracts that would have reduced reimbursement rates to providers.

Residency funding urgently needed to address work force shortage

“It’s all about making more money, not improving care,” he said. “That’s what these mergers are all about.”

Still in play is CVS’s acquisition last year of Aetna, which is being held up by U.S. District Court Judge Richard Leon in Washington.

The AMA and its Council on Legislation, chaired by Dr. Underwood, brought together legal and academic experts and determined that the merger would have been anticompetitive and would have had “deleterious effects on both patients and physicians.”

After the U.S. Justice Department approved the merger, the AMA filed comments to Judge Leon and then filed an amicus brief explaining why Aetna’s proposed divestiture would fail to restore competition in the prescription drug plan market to premerger levels, one of the concessions CVS/Aetna needed to make to win government approval.

Dr. Underwood said he welcomes the opportunities offered by his new position on the AMA Board of Trustees, which he feels will allow him to make a real difference for patients and physicians alike.

“I look forward to playing a role in the AMA’s push to unlock the promise of a healthier nation,” he said. 

Willie Underwood, III, MD, MSc, MPH, the Buffalo, NY urologist elected to the American Medical Association’s Board of Trustees in June, believes physicians must step up and help influence governmental decisions designed to improve and expand health care for all Americans.

Author | Bob Gatty

Articles

Report urges action on physician burnout

Urology groups: 340B program reform needed

Advocates work toward Office of Men’s Health

Urologist elected to AMA Board of Trustees