Is it Time to Reevaluate the C-Suite?

“I do not believe you can do today’s job with yesterday’s methods and be in business tomorrow.” – Nelson Jackson

 As the dynamics of our country’s health care system change, so too must our methods of managing the intricate web of patient encounters. We have all heard the buzzwords “population health,” “bundled payments,” “full risk” and “value-based purchasing.” These phrases signal the movement from a reimbursement model predicated on frequency to one based on patient outcomes. In essence, the new reimbursement paradigm forces us to reconsider yesterday’s methods.

 Traditionally, hospitals used their resources to report quality data, as required by the Centers for Medicare & Medicaid Services (CMS). They maximized reimbursements by capturing all patient comorbidities and by working with physicians to minimize the length of stay. This model improved the profit margin with medical DRGs such as CHF, AMI, stroke, pneumonia and COPD by standardizing care, improving quality and lowering costs. Surgical services were the financial engine for hospitals because of their high per-case contribution margin. Administrative oversight was limited mainly to staffing and support services since there was little need for standard evidenced-based practices. Recently, this dichotomy has expanded on a national scale with DRG improvement projects focused solely on medical disease states.

 Now, however, with payment structures shifting away from a DRG-based fee-for-service, surgical services are quickly becoming a cost center. Hospitals thus require an entirely different C-suite structure, and along with that change comes the need for a new administrative skill set.

 ASA has proposed a concept to address the current fragmentation in surgical care – the Perioperative Surgical Home (PSH). The PSH is a patient-centered, physician-led, multi-disciplinary and team-based system of coordinated care. It guides the patient through the entire surgical experience from decision to discharge. The PSH is above all value-based and thus provides a strategic opportunity to engage both employers and payers.

 With the aim of meeting the dual goals of improving workforce health and decreasing productivity loss, employers sit at the forefront of health care redesign. This is a tremendous responsibility that demands an administrative skill set, oversight and vision currently lacking in the C-suite. Senior management positions have ballooned over the years to keep up with the complexities of medicine. In addition to the traditional positions of CEO, CFO, CNE and CMO, hospitals now have a Chief Experience Officer, a Chief Population Health Officer, a Chief Innovation Officer and a Chief Information Officer.  Is the current composition and influence of senior leadership commensurate with changing health care needs? Is it time to reevaluate the C-suite?

 We should base who gets a seat atop the physician executive administrative pyramid on who is capable of reducing clinical variation and fragmentation in care. Leaders should be visionary, capable of working with multidisciplinary teams and able to improve quality in measurable ways. The cost of C-suite positions is no doubt high. The positions, either directly or indirectly, need to reduce costs and improve quality under risk-based and capitated contracts. On the other hand, if there is a managerial gap in a vital clinical area such as surgical services, then organizations need to create positions that will secure the critical outcomes essential for future financial viability.

 Ultimately, I ask: Is it time to break up the chief medical officer role? Historically, the CMO served as the conduit between physicians and senior management, focusing solely on inpatient medical care. In the new health care paradigm, clinical management oversight must span the entire spectrum of a patient’s episode of care. It cannot be confined solely to encounters in the hospital. This oversight is now impossible to manage with one position. It is my belief that the creation of a Chief of Medical Services (COMS) and Chief of Surgical Services (COSS) is necessary for the success of any health care system.

The Perfect Storm

The confluence of clinical complexity, risk contracting and fragmented care has created a fertile climate for the creation of the Chief of Surgical Services as an integral member of the C-suite. No health care organization can succeed without visionary leadership in the surgical specialties. Below is a tentative list of COSS responsibilities:

1.  Coexist in a shared operative environment with maximal utilization of services by developing a sustainable infrastructure that supports the surgeons, anesthesia and the patients they both serve

2. Decrease clinical variation with the aid of robust databases and clinical analytics.

3.  Consolidate high-acuity procedures so as to reach the critical volume necessary for an efficient supply chain, specialized nursing care and standardized anesthetic management.

4.  Develop surgical programs spanning preoperative assessment through post-acute care that demonstrate high quality and value for the surgical patient, in keeping with the ASA’s PSH.

5.  Matrix with medical subspecialties to maximize patient preparation and perioperative management through post-acute care.

6.  Develop centers of excellence for local, regional or national destination surgeries.

 While the benefits in the establishment of the COSS position are self-evident, there are a number of barriers to establishing this new role:

1.  It is a new idea, and health care organizations are risk averse.

2.  In a climate of decreasing reimbursement, adding another C-suite position is a tough sell.

3.  Most CMOs across the country have a primary care background. There is an understandable lack of local knowledge, resulting in the inability to see the gap in surgical leadership or “share the turf” with an additional senior physician colleague.

4.  Nationally, surgical services oversight and visionary planning resides with a COO, who commonly lacks experience in the intricacies of surgical services and may balk at expanding the C-suite table.

 There are currently too many departments and too many chiefs, which has contributed to the fragmentation in services and patient care that we now confront. Any consideration of a new C-suite position must, of course, pass the test of improving coordination and integration in the delivery of clinical services. Equally important is the ability to decrease clinical variation, resulting in higher quality and lower costs. Answering the call would be a physician executive armed with the tools of local surgical service knowledge, proven leadership skills and advanced management training. The following case study illustrates what is at stake:

 EdisonHealth, Westlake, Ohio.

 ■ EdisonHealth selects destination hospital “Centers of Excellence” based on appropriateness of care.
 ■ Hospitals receive an “aggressive, all-in” payment for spine, valve or transplant surgeries.
 ■ Covered patients receive consultations, care coordination (similar to the ASA’s PSH approach), plus travel, food and lodging.
 ■ Destination surgical services are covered at 100 percent.
 ■ The local surgical option requires deductibles and co-payments.
 ■ An employer with 10,000 employees can expect 10 to 20 employees selecting the destination surgery option and up to $2.5 million in health plan cost savings.

 As we can clearly see, when surgical care becomes coordinated, less fragmented, economized and based on large volume, low clinical variation, aligned financial incentives and strong, visionary administrative oversight, the desired financial results will follow.

 With the addition of the newest member to the health care C-suite, the Chief of Surgical Services, we now have the opportunity to fill this senior leadership gap and ensure the viability of systems looking to prosper amid the continued paradigm shift in American health care.

Myles Gart, MD

Pain is not the fifth vital sign

After years of exaggeration, misinformation and a national epidemic of opioid and heroin abuse, the nation is finally coming to terms with the fact that pain is not the fifth vital sign. This heresy, as I understand it, has existed for close to three decades and, in my opinion, has been directly responsible for the in hospital deaths of thousands of patients as well as lethal drug overdoses of hundreds of thousands of American citizens through illicit opioid use.

 The misguided acceptance of pain as the fifth vital sign has been, and still is, the single biggest mistake in the history of modern medical pain management.

 In the early ‘90s, the American Pain Society opined that there was a national epidemic of untreated pain in our nation’s hospitals and announced that pain should be classified as the fifth vital sign. This assertion is riddled with many problems. Vital signs are clinical measurements, specifically: pulse rate, temperature, respiration rate and blood pressure, that all indicate the state of a patient's essential body functions.

 These clinical measures are very objective in character and include an assortment of relevant numerical values. Pain is a subjective feeling that is impossible to accurately and consistently quantify across patient populations. Therefore, in order for providers to assess pain as a vital sign, they must ascribe a numerical value for it, such as zero to ten based on the Universal Numeric Pain Scale.

 As a result of equating pain as a vital sign, medical practitioners must come up with a reliable and effective treatment if and when a patient subjectively rates their pain high on the scale.

 In 1998, the Federation of American Medical Boards issued a policy reassuring physicians that “in the course of treatment,” large doses of opioids were acceptable. In 2001, the Joint Commission mandated that hospitals across the country assess pain on each patient they treat.

 While not stating how facilities should assess pain, the nation relied on what the prevailing though was: pain should be considered the fifth vital sign and treated on the zero to ten pain scale. With the support of the Joint Commission, The Federation of American Medical Boards urged individual state medical societies to make the under treatment of pain punishable for the first time.

 With misinformation and external pressure by state and national oversight agencies, American hospitals and medical professionals were steered toward the over treatment of acute and chronic pain. Failure to comply was tantamount to patient abuse and battery, punishable by citations from medical boards and the Joint Commission.

  Thus, this “virtual” national epidemic of untreated pain and subsequent adoption of pain as the fifth vital sign has, in my view and the view of many clinicians, resulted in the brutal and harsh reality of a national opioid and heroin crisis. As evidence, since pain received this additional focus, the number of prescriptions for opioids has escalated from around 76 million in 1991 to nearly 220 million in 2011.

 Looking at some recent data from the American Society of Addiction Medicine, one can truly see that the adoption of pain as the fifth vital sign resulted in many adverse and unintended consequences:

 ·      Drug overdose is the leading cause of accidental death in the United States. There were 47,055 lethal drug overdoses in 2014 alone. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers and 10,574 overdose deaths related to heroin;

 ·      From 1999 to 2008, overdose death rates, sales and substance-use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate;

 ·      In 2012, 259 million prescriptions were written for opioids, which, in numeric terms, equates to one bottle of pills for every adult American;

 ·      Four out of five new heroin users started out misusing prescription painkillers. As a consequence, the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013. In 2014, more than 467,000 adolescents were non-medical users of a pain reliever.

 How do we pull ourselves out of this opioid abyss and begin to reverse these sobering statistics?

 First and foremost, we must bury the claim of pain being the fifth vital sign and replace it with a 21^st Century pain assessment tool that incorporates objective evidence and measures of pain. We must provide improved pain management education for our healthcare providers. In June 2016, The American Medical Association (AMA) removed pain as a vital sign.

 The AMA was followed, in September 2016, by the American Academy of Family Physicians (AAFP). The AAFP voted to drop pain scores as the fifth vital sign, partly in reaction to being seen as a scapegoat for the nation’s opioid overdose epidemic. Even Tom Frieden, MD, MPH, director of the Centers for Disease Control, has called the opioid epidemic “doctor driven.” But physicians in many specialties have explained that they feel pressure to overprescribe opioids, and do so to attain higher patient-satisfaction scores for themselves and their hospitals.

 The Joint Commission must also take steps to remove the threat of hospital sanctions for the perceived under treatment of pain. The federal government, likewise, through the Centers for Medicare & Medicaid Services, must move toward the removal of the so-called subjective patient assessment of pain from the value-based payments that hospitals receive.

 At the same time, when the shackles of state and federal oversight pressures are finally removed, we must embark on a national education program, with the primary emphasis on safely and effectively managing patients with acute and chronic pain.

 For more than three decades, opioids have been the foundation of acute pain management. In 2014, a database consisting of close to three million patients revealed that 73% of those in hospitals receiving intravenous analgesics received only opioids. That number should be zero! The standard of care for acute pain management should be based on a non-opioid platform, better known as a multimodal analgesic (MMA) approach for balanced pain management. Many professional and regulatory organizations support the MMA approach, since there has been mounting evidence that this method reduces the amount of opioids required, resulting in improved patient safety and outcomes.

Failure to comply with this particular approach would result in unnecessarily exposing hospitals and healthcare providers to medical liability. Reducing or eliminating the need for opioids in the hospital setting is not only a mandatory risk mitigation tool but also a way of improving the prescribing practices outside the walls of healthcare institutions.

 Let us work together to take pain as a vital sign out of our lexicon and begin a new campaign to manage pain in a way that is safe and effective. Inaction is not an option. When faced with the embarrassing fact that the United States makes up just 4.6 percent of the world’s population yet consumes more than 80 percent of the global opioid supply, decide for yourself whether a change in our pain treatment paradigm is urgently needed.

Myles Gart, MD

Isn't it time for a 21st Century Pain assessment?

The evaluation of pain is extremely difficult due to its subjective nature. We need to move to an evaluation of acute pain that not only takes the patient’s perception into account, but also, for the first time, incorporates objective measures of pain into a global assessment matrix.

When a patient is in pain, either from an injury or surgical procedure, the pertinent question should be, “is the pain tolerable?” Each of us has a threshold at which point the addition of an analgesic should be considered to prevent the consequences of untreated acute pain.

  

This threshold should not be based on an arbitrary numerical value, but whether the pain is tolerable for that individual. Once the patient states that their pain is intolerable, we then attempt to correlate this subjective feeling with the following objective measures prior to the initiation, maintenance and escalation or de-escalation of analgesic treatment.

Here is a mnemonic to aid in remembering the objective measures of acute pain:

Opioids Rarely Help Bodily Pain

·      Observation—Is the patient grimacing, screaming, diaphoretic, combative, crying, sleeping, drowsy, etc.? This observation must be made after confirming that the physical/verbal symptoms are not due to delirium, hypoxemia, hypercarbia, acidosis or other metabolic issues that may be confused with the outward appearance of discomfort. Once it is established that the physical signs are due to pain, you can proceed with analgesic treatment. If, however, you have not established that your observation is from pain, or if the patient appears drowsy, somnolent or obtunded, do not give analgesics.

·      Respiratory Rate—In my opinion, respiratory rate in the presence of a patient stating that their pain is intolerable is the most important indicator and guide for analgesic therapy. A normal respiratory range is between 12-20 breaths per minute. These are actual breaths associated with ventilation of a normal tidal volume. They are not attempted, shallow or obstructed respirations. Once it is confirmed that there are no abnormal neurologic, metabolic or psychological issues involved, the respiratory rate may now be assessed. A true respiratory rate greater than 20 with a patient stating intolerable pain is a good indication for analgesic treatment. If, however, the respiratory rate is less than 12, I would not initiate or escalate opioid analgesic therapy.

 ·      Heart Rate—Heart rate is usually elevated when a patient has intolerable pain, but just like any other objective measure, other factors may also come into play. If a patient is on a beta blocker, the heart rate response to pain may be masked. In addition, if a patient is hypovolemic, hyperthyroid, hypercarbic or has a hyper-dynamic neuroendocrine disorder, the heart rate may be misleading.

 ·      Blood Pressure—Blood pressure is usually elevated when a patient has intolerable pain. However, as with heart rate, other factors must be taken into consideration prior to attributing the elevated blood pressure to pain. In addition, all objective measurements should be compared to the patient’s pre-pain baseline. For example, if a patient had a baseline blood pressure of 160/90, then 160/90 would not be considered as an indication of acute pain with this individual.

·      Pupil Size—It is an often-missed indicator of pain, however, pupil size may not only indicate severe pain, but also help guide narcotic de-escalation. For example, if a patient is in pain, there are increased circulating catecholamines from sympathetic stimulation. This leads to pupillary dilation. On the other hand, pinpoint pupils can indicate the central nervous system’s response to a therapeutic narcotic level. Can narcotics be titrated to pupil size? No, but pupil size can definitely be used as a guide in the treatment of acute pain.

Putting it all together

Our first approach in the assessment of acute pain is to observe with critical attention the objective indicators of pain: heart rate, blood pressure, respiratory rate and pupil size. If your evaluation shows a patient who is resting quietly in bed with a heart rate of 60, blood pressure of 120/80, respiratory rate of 12, what then is your initial impression prior to asking for the patient’s “feeling?”

Based on the objective measures, I would maintain current analgesic levels. When asked, however, the patient does not respond how you would expect and rates their pain as intolerable. This is the dilemma facing healthcare providers on a daily basis and their resolution is to escalate analgesic therapy with opioids over 90% of the time.

 This mistake stems from recommendations, such as those from the Agency for Healthcare Research and Quality, whose position is that “patients’ self-reports are the most reliable indicator of their experiences of pain.”

 This line of reasoning is devoid of any objective measures and places the patients’ “self-reports” as the cornerstone in an acute pain management protocol. In addition, the reliance solely on the subjective measure of a patients’ self-report exposes providers to unnecessary legal consequences of under-treatment as well as opioid over-treatment resulting in possible respiratory morbidity, mortality or long-term addiction if this model is continued into the outpatient setting.

 While the legal implications of the way practitioners assess and treat acute pain in the hospital and post discharge are beyond the scope of this article, it is important to note that hospitals, pharmaceutical companies and practitioners are being sued for mortalities related to the inappropriate prescriptive use of opioids.

 As for big pharma, their culpability lies in the inaccurate education and detailing of opioids as either not as addictive or not as dangerous as they truly are.

 The objective measures of pain and critical thinking of where a patient is relative to where they were or where they should be, is requisite prior to the patient’s self-report of whether they view their pain as tolerable or intolerable. When married together into a global pain matrix, these measures will guide the practitioner with the initiation, maintenance, escalation or de-escalation of analgesic therapy. In my experience, nurses feel that they will be reprimanded if they withhold analgesics from a patient who has rated their pain a nine out of 10 on the universal pain scale. This fear routinely leads to unintended consequences.

Myles Gart, MD