The most insidious issues in healthcare

There are many systemic issues that all healthcare professionals are forced to grapple with, including staffing shortages, rising practice costs and decreasing reimbursement.

However, some issues affecting all of healthcare do not make as many headlines. 

Becker's connected with 15 physicians to discuss the problems the industry is facing that are not as widely considered.

Note: These responses have been edited lightly for length and clarity.

Question: What is the most insidious issue in healthcare?

Richard Gitomer, MD. Internist and Medical Director for MDLIVE Virtual Primary Care (Miramar, Fla.): Americans face significant challenges in accessing primary care, the consequences of which are people delaying care, which leads to unnecessary ER visits, avoidable hospitalizations and readmissions, and preventable declines in chronic care patients.

There is little argument surrounding the value of primary care in improving outcomes and reducing costs, yet the country continues to face a frightening decline in the number of primary care physicians. Unfortunately, the compensation model compared to the expectations and workloads of PCPs doesn't make it an attractive path for doctors.

Primary care providers need the resources necessary to invest in the talent and technology they need to increase access to data, streamline administrative functions, expand care coordination capabilities and improve patient communication.

Ian Glass, MD. Chief Quality Officer at Houston Methodist Willowbrook Hospital: I believe that not adhering to evidence-based medical practices and processes in the diagnosis and treatment of patients is healthcare’s most insidious issue. This promotes poor patient outcomes, wastes untold billions of dollars, and is inconsistent with high-reliability tenets that promote the highest quality and patient safety. 

Sachin Gupta, MD. Chief Medical Officer at UNC Physicians Networks (Morrisville, N.C.): One of the most insidious issues in healthcare is disparities in access and quality of care, which disproportionately impacts marginalized communities based on factors like geographic  location, race, language, health literacy and socioeconomic status. COVID really brought to light these disparities when it came to early testing and access to therapeutics and vaccines. It takes diligent, dedicated work to help break down these barriers to expand access and high-quality care to those populations who are in greatest need.

Agnes Hurtuk, MD. Assistant Professor and Ambulatory Medical Director of ENT at Loyola Medicine (Chicago): The growing national shortage of physicians and its impact on healthcare delivery and quality of care is one of the most insidious issues in healthcare. Over the last several years, I have had an increasing number of patients that I see in my otolaryngology practice ask me to refill their blood pressure medications or an inhaler for their asthma because their primary care physician has left the state, retired, is no longer accepting their insurance, or is booked for a long period of time and unable to see them in a reasonable amount of time. Patients are having increased difficulty establishing care with primary care physicians, and as we all know, the pathway to good health starts with a good relationship with a primary care physician.

In order to address this issue, it is first important to quantify and understand the current physician supply, areas in need, capacity of current practicing physicians, and how long they plan to practice. In addition to understanding the current physician pool, it is also important to understand who will replace or help these physicians when they leave practice, retire or reach volume where they need help from another physician with the patient load. Currently, there are no reliable answers to these questions. 

One estimate states that approximately 83 million people in the U.S. currently live in areas with limited access to primary care physicians. As the U.S. strives to provide a more equitable and affordable healthcare system, there needs to be a better understanding of the supply of physicians and demand to achieve adequate access and maintain the high-quality care for which the U.S. healthcare system is known worldwide.

It is important to understand the possible etiologies behind the current and anticipated physician shortages to address them. While this may not apply to all specialties, there are several factors that can be looked at to improve workflows for physicians, such as decreasing unnecessary administrative burdens, capacity enabling technologies such as telemedicine or virtual or digital charting support and investigating other factors to improve physician job satisfaction. 

Once these etiologies are better defined and quantified, these issues can be effectively addressed, and this, in turn, will continue to attract the best and the brightest candidates to medicine to move U.S. healthcare forward with research and innovation to provide the highest quality care to our patients and communities.

Nadimire Jules-Dole, MD. Psychiatrist at Paragon Integrative Health (Ellicott CIty, Md.): 

  1. Low insurance reimbursement rates. Physicians are either not accepting certain types of insurance because of low reimbursement, which decreases the pool of available providers who take insurance, or being forced to see more patients in a shorter amount of time to make up the cost, which contributes to burn out. Our healthcare system is expensive, and it is important for us to develop innovative ways to spend responsibly and also properly compensate for those who are providing quality care.
  2. Medical documentation burden. Excessive time and energy is spent by physicians due to clinical recordkeeping. It is important for us to streamline what is absolutely necessary from a medical, legal and compliance perspective. We should continue to research how to reimagine clinical documentation using technology such as artificial intelligence in order to improve efficiency, accuracy and reduce burnout.
  3. Responsible use of artificial intelligence technology. It is an exciting time because there are so many potential benefits of AI in the healthcare space. However, we also have to be careful how we use this technology given the risk for misuse and abuse.

Rahul Kashyap, MD. Medical Director of Research at WellSpan Health (York, Pa.): One of the most insidious issues plaguing the healthcare sector today is the challenge of recruiting and retaining high-quality staff. This multifaceted problem encompasses shortages across various roles, including doctors, registered nurses, health IT specialists and researchers, which is exacerbated by the projected deficits expected by 2030 in the United States. According to the Association of American Medical Colleges and the Health Resources and Services Administration, there will be a combined shortage of over 120,000 doctors and registered nurses by 2030, leading to increased strain on healthcare systems and compromised patient care.

Moreover, the issue extends beyond mere recruitment, as retention rates within these professions are also alarmingly low. This can be attributed to various factors such as the changing work preferences of newer generations, including Generation Z and Generation Alpha. These generations often prioritize a flexible work-life balance, which may translate to a tendency to switch jobs frequently or pursue telework options. As a result, healthcare institutions face the challenge of retaining talent and maintaining institutional memory, which is crucial for providing consistent and high-quality care.

The constant turnover also leads to increased costs associated with recruitment, training and onboarding of new staff members. Furthermore, the shortage of skilled professionals in critical areas like health IT and research can hinder advancements in medical technology and treatment methodologies, ultimately impacting patient outcomes.

Addressing the issue of recruiting and retaining staff in healthcare requires a comprehensive approach that considers factors such as job satisfaction, work-life balance, and professional development opportunities. Healthcare institutions must adapt their recruitment (such as quicker interview and hiring decision making) and retention strategies (such as mentoring opportunities, clear pathways to promotions) to align with the evolving preferences of the workforce. Failure to address this issue effectively will have far-reaching implications for the future of healthcare delivery.

Jason Knight, MD. Chief Medical Officer at Houston Methodist The Woodlands (Texas) Hospital. The most insidious issue in healthcare is that hospital reimbursement continues to stay relatively flat or decline while the cost to provide care to patients continues to increase at a robust rate. 

The salaries of hospital doctors, nurses, and staff employees are going up in an effort to somewhat keep up with inflation. The costs of medications and drugs are higher and continue to increase. The costs of supplies to provide care to patients are increasing. The cost of equipment and new technology continues to move higher. 

Additionally, the Medicare Advantage denials and insurance company payment denials of procedures, hospitalizations, advanced testing, medications and care is gradually and subtly creating an unsustainable compression on hospital margins. In the near future, hospitals are going to need to cut certain important services for patients due to those medical specialty service lines becoming financially unsustainable.

For example, our hospital loses money on the vast majority of Medicare internal medicine admissions. Providing that care is critical and important. Commercial insurance patients are indirectly subsidizing low Medicare and Medicaid reimbursement rates for our hospital and on a broader scale in this county. Is this fair and equitable?

It is going to be critical going forward to not let the revenue and expense lines cross while managing hospital service lines to continue to provide important and necessary care to patients and our respective communities.

Peter Lewy, MD. Pediatric Nephrologist at Endeavor Health NorthShore Hospitals (Wilmette, Ill.): I think it is the purchase of health care systems by nonmedical investment entities who are ignorant of the needs of good medical practice and whose only goal is making money while degrading the quality of medical care.

Nathan Merriman, MD. Medical Director of Gastroenterology and Digestive Health at Intermountain Health (Salt Lake City). I believe the answer is friction. Friction is often insidious in healthcare workflows. The human energy expended, stress experienced, and time spent by patients and care team members to overcome unnecessary friction add up over time. I believe this friction contributes to aggregate stress, avoidance of painful processes and workflows, potentially counterproductive workarounds, and even burnout. We need to make it easier for our care teams and patients to get the right things done and make it harder for the wrong things to happen. One important point with friction analysis is there are forms of good and bad friction in every organization and team. It takes teamwork to analyze good and bad friction to improve the balance of friction and flow for patients and care teams together. As Bob Sutton and Huggy Rao share in "The Friction Project," we can all be friction fixers in our organizations and teams.

 Aparna Padiyar, MD. Nephrologist at University Hospitals (Cleveland): I believe the most insidious issue in healthcare is inertia, the idea that nothing has changed, nothing will change, no one can change the system so I won’t even try. It is understandable how we get there — comfort with the status quo, being overwhelmed with the behemoth of modern healthcare, fear of change, the feeling that you are only one individual. But we are at a point now where so much good can be done with new technologies, new medications, new recognition of what constitutes health, and simply new ways of doing old things. Imagine the force that could be generated if everyone committed to overcoming inertia and believing that change was possible, even just one small single step at a time. That would truly be transformative.

Joseph Sebeo, MD. Chief Strategy Officer at PreferredMD Solutions (New York City): The national shortage in registered nurses has steadily increased in recent years and is only expected to intensify in the next decade. According to a 2020 National Nursing Work Survey, the median age for RNs was 52 years old, pointing to a significant need for new hires between 2030-2035. In 2019, the United States Workforce Report Card and Shortage Forecast projected a nursing shortage was anticipated for the majority of U.S. states by 2030.

In 2023, the Bureau of Labor Statistics agreed, projecting 177,400 total new RNs would be added between 2022-2032, while the demand for new RN positions was projected to reach 193,100 per year during that same period: these include new nursing positions as well as replacing RNs leaving the labor force, changing careers or retiring. Even if overestimated, this large imbalance highlights a significant challenge for our healthcare system.

It appears RNs are likely to face an increased number of patient-related tasks with less time to accomplish them. How can we maintain our RNs' ability to provide the highest level of patient care in the safest manner in an environment where they are in shortage and are having to take on increased workload?

Additional support at the policy level can help, including statewide initiatives such as the approval of a state-funded new school of nursing pavilion in Florida this past year. The use of technology can provide another possible answer to the nursing workforce shortage.

However, not all technology solutions are created equal. While it can alleviate some of our RNs' tasks, even with the right intent, technology can lead to the opposite effect and increase the workload for nurses. Technology in healthcare needs to be comprehensive yet simple, goal-oriented yet user- friendly, and nurses need appropriate training. Physicians and RNs should aim to actively get involved in the conversations related to the development of the technologies they will have to use. Only then can we ensure these digital tools address the actual clinical issues of daily patient care and alleviate the workload of our nurses, instead of adding more burden.

Patrick Torcson, MD. Senior Vice President and Chief Medical Officer at St. Tammany Health System (Covington, La.): The current payment model of fee-for-service reimbursement through third-party payers is the most insidious issue in US Healthcare, in my opinion. The structure and incentives in this model limit access for patients, do not promote optimal clinical outcomes for patients and do not adequately address the social determinants that account for 80% of health.

Likewise, for payers including the government, employers and of course individuals, healthcare coverage is unsustainably expensive resulting in individual and family economic insecurity and an overall drag on the economy.

Finally, the fee-for-service payment model has led to significant production pressure on providers resulting in burnout, a sense of moral injury and disillusionment with the healthcare profession.

All of the issues noted above have been intensified post COVID, and there does not seem to be a clear vision toward an overall reform of the payment system.

Donald Yealy, MD. Chief Medical Officer and Senior Vice President, Health Services Division, UPMC; and Chair, Department of Emergency Medicine, University of Pittsburgh Physicians: The challenges awaiting the healthcare workforce comprise the biggest insidious challenge – insidious in that it has many manifestations, often not apparent but real. The known physical and emotional demands of the professions will persist, but job requirements will grow. To give good care, those in healthcare will require new skills, have different roles and responsibilities, interface with each other and those being served in alternate ways, and integrate new technologies, notably artificial intelligence and personalized care materials. All of this will change things dramatically but not at once, meaning our team members will need new training and support that is not here now. These new approaches and programs are nascent now but must evolve.

David Zarkou, DPM. Vice President and Executive Medical Director at Saint Alphonsus Medical Group/Saint Alphonsus Health System (Boise, Idaho): The first thing that came to my mind when thinking about the most insidious issue in healthcare is the burnout of our caregivers-physicians, clinicians, nurses and other caregivers. Many of our colleagues suffer in silence. However, it deeply affects them, their patients and their loved ones. The increases/demands in the administrative burdens on caregivers, staffing shortages, and increases in violence against healthcare workers are just a few of the challenges that our frontline healthcare workers face.

If I could add a second insidious issue in healthcare, it would be the shortage of caregivers that we currently face-including physicians, other clinicians, and nurses.  While the new estimates by the AAMC showed a decrease from previous projections in primary care and specialty physician shortages, patients and healthcare systems are already feeling the effects, which will continue to get worse. Patients in many areas wait months to get established with a primary care clinician or to get into see a specialist. Patients in rural areas are traveling further to get care.  Hospitals and health systems in many areas across the country have been forced to close services due to shortages, not only of physicians-but other caregivers as well.

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