Medical Group Management Association Research Articles

IntroductionSurgical residents make decisions that may have a dramatic impact on career earnings based off conceptions regarding future income potential. This study examines the effect of debt burden, repayment plan, and practice setting on a general surgeon's career value. MethodsDebt levels, repayment plans, and practice setting were considered to model a surgeon's career value using net present value (NPV) across 35 scenarios. The NPV was calculated using salary, education debt, yearly spending, and a discount rate of 5%. Salary data were obtained from the Medical Group Management Association, student debt information from the Association of American Medical Colleges, and tax and household spending data from U.S. government records. Assumptions included no gaps in training, no prior debt, single-person household, and career duration of 35 y. ResultsA general surgeon's salary adequately repays debt burdens from $100,000-$300,000 over 10-25 y, regardless of repayment plan or practice setting. Practice setting decreased career value for academic surgeons when debt burden and repayment plan were held constant: the NPV for an academic surgeon was $382,000 compared to $500,000 for a nonacademic surgeon with the same debt and repayment plan. Debt burden repaid through unsubsidized and income-based repayment plans reduced NPV for all surgeons, while subsidized plans increased NPV. The projected NPV for all scenarios ranged $2.35M-$2.87 M. ConclusionsThough the modeled scenarios do not account for prior debt burden, major expenditures, or increases in yearly household spending beyond national averages, surgery residents should be aware that general surgery remains a financially feasible career.

Previous comparisons of potential lifetime earnings between general pediatricians and pediatric subspecialties have demonstrated that many subspecialties have lower potential lifetime earnings than general pediatrics. However, those studies selectively used specific data sources for different portions of analyses. To assess the presence and magnitude of differences in earning forecasts using different authoritative data sources. This quality improvement study analyzed compensation data for 14 pediatric subspecialties and general pediatrics from the Association of Administrators in Academic Pediatrics (AAAP), Association of American Medical Colleges (AAMC), and Medical Group Management Association (MGMA) for the 2021 to 2022 academic year. The potential lifetime compensation was calculated using the net present value (NPV), which accounts both for compensation throughout training (residency and fellowship) and compensation after graduation. The potential lifetime compensation for the subspecialties and general pediatrics was compared separately for each data source. This study included data from 3 sources about 14 subspecialties and general pediatrics. Depending on the data source, the magnitude of the difference in lifetime earnings between subspecialties and general pediatrics varied greatly. For all sources, there was a greater difference in lifetime earnings between higher- and lower-paid subspecialties compared with each other relative to general pediatrics. For the AAAP, the subspecialty with the greatest lifetime NPV is neonatal medicine, and the subspecialty with the least lifetime NPV is endocrinology, with a difference of $2 787 539. For the AAMC, cardiology has the greatest lifetime NPV and endocrinology the least, with a difference of $3 557 492. For the MGMA, neonatal medicine has the greatest lifetime NPV and adolescent medicine the least, with a difference of $4 210 477. Additionally, there is a notable difference in lifetime earnings in private vs academic practice. These findings suggest that the difference in lifetime compensation between many pediatric subspecialties and general pediatrics is not as large as previously reported. Also, greater differences exist when comparing private practice vs academic medicine and between higher- and lower-paid subspecialties.

Prior authorizations (PAs) are a means by which insurance companies ostensibly regulate the overutilization of costly medications and medical services. While controlling health care costs is an important consideration, PAs are increasingly criticized for the administrative burdens placed on health care practices and providers, with resultant delays in patient care and the potential for harm when patients are unable to get their indicated treatments/services. Acknowledging these criticisms while balancing the need for prudent resource management, a consensus statement for improving the PA process was put out in 2018 by the American Medical Association (AMA), American Hospital Association, America's Health Insurance Plans, the American Pharmacists Association, Blue Cross Blue Shield Association, and the Medical Group Management Association emphasizing the need for reform.

Advanced practice providers (APPs) are integral members of the healthcare delivery team. However, there has been a lack of standardization and uniformity in how they are utilized across inpatient, ambulatory, and procedural settings. A multidisciplinary workforce planning committee was formed in March 2021 to evaluate all new and replacement full-time equivalent APP positions at Stanford Health Care (SHC), an academic medical center of more than 600 APPs, to optimize and standardize the role of APPs as per national benchmarks. Six months since the launch of the committee, there has been a 10% increase in the number of visits and procedures performed by APPs providing better access for patients. In addition, there has been a 38.7% improvement in ambulatory APPs meeting their productivity target, 19.4% improvement in ambulatory APPs meeting utilization targets, and 36.8% improvement in ambulatory APPs meeting the 50th percentile and above as per the relative value unit benchmark published by the Medical Group Management Association for Academic Medical Centers. For inpatient APPs, there has been a 38.8% improvement in APPs meeting the average daily census target. APP utilization is an important topic that has not been consistently addressed in the literature. Inappropriate utilization and lack of top of licensure practice have been associated with increased turnover, decreased job satisfaction, and professional development. By developing a multidisciplinary workforce planning committee, full-time employee positions are evaluated with a goal of optimizing and standardizing the role of APPs at SHC.

“Purpose is not about what we do and how fast we do it; but why we do it, and how we do it.”Paolo GalloThe pandemic catapulted the post-acute and long-term care environment into multiple crises simultaneously, which made caring for our most vulnerable community members a monumental endeavor. The bandages of a largely dysfunctional system have been ripped off, and we are figuring out how to stem the bleeding long enough to create a functional health care system that not only serves the people who need care but also the caregivers themselves. As Professor David Grabowski has said, “We’ve overlooked and undervalued this workforce for a long time, and now we’re at a full-blown crisis” (Skilled Nursing News, Mar. 10, 2022, https://bit.ly/36kCeem).In response, many leaders are trying to find meaningful ways to support staff well-being with strategies that include increased pay, extra paid days off, cards reading “I’ll be back in 15 minutes” to give staff permission to take breaks, employee-of-the-day recognition, thank-you cards for staff who have done nice things, and food — lots of food. But when the meal is over, the card is read, and the employee returns after a paid day off, has anything changed? Or is the facility culture still “business as usual”? Although these extrinsic strategies are welcomed and enjoyed by staff, they fall short of what’s needed to strengthen staff well-being and, ultimately, retention.According to a webinar hosted by the Gerontological Society of America, even if a facility eliminates the influencing factors that lead to turnover, it doesn’t that mean staff will stay (“Common Data Elements for Workforce and Staffing in International Long-Term Care Research,” Sept. 3, 2020, https://www.youtube.com/watch?v=qLdcdeUxhUs). This is in part because, despite all positive efforts, the staff still are being pushed to accomplish an ever-growing list of tasks on top of their job descriptions, and they go home feeling discouraged, resentful, exhausted, and numb.Contributing to this crisis is a phenomenon called the “just-get-over-it culture,” where health care staff are expected to adapt quickly to changing circumstances and not spend time processing their emotions (M. Goulston and D. Hendel, Why Cope When You Can Heal, Harper Horizon, 2020). But human beings are not meant to function by ignoring their physical and emotional needs while being pushed to work harder and faster no matter the cost to their well-being.We can continue to treat people as “human resources” — viewing them as materials we obtain, shape, use, then throw away (as described by Del Nelson in Henry Neave, The Deming Dimension, SPC Press, 1990) — or we can choose differently.Choosing DifferentlyAccording to Davis Balestracci, an individual’s perception of the work environment is crucial (“Data ‘Sanity’: Statistical Thinking Applied to Everyday Data,” Medical Group Management Association, 2015). If staff’s perception is that they do not matter or that they do not belong, that is their daily reality. And what’s more, that perception influences the leadership’s reality as well. Balestracci teaches the concept of “bolted-on” versus “built-in” culture. Bolted-on cultures eventually rattle loose and fall off, risking staff frustration and, worse, cynicism. Built-in cultures are sustainable, woven into the facility cultural fabric.How can we create a built-in culture that makes PALTC staff want to stay? The following are a few thought shifts that we can make to the ways that we perceive the problem in order to affect the ways that we see the solution. They will help us move from bolted-on strategies to built-in strategies.One: Extrinsic Versus Intrinsic MotivationWe can choose to create facility cultures where intrinsic motivation can thrive, forgoing extrinsic motivational factors like stars, rewards, and the looming fear of discipline. Intrinsic motivation is entirely different than doing something out of fear, competition, or being shamed with discipline. Intrinsic motivation is driven by human needs for purpose, fun, learning, belonging, self-knowledge, and passion. When we do things because we genuinely love to, we bring our full self to the experience. Working with staff to understand and create intrinsic motivation is an important part of the process.Two: Job Versus RoleYou may recall the story of two stonecutters: when asked what they are doing, the first says, “I’m cutting this stone into blocks,” and the second says, “I’m on a team building a cathedral.” Similarly, this difference between a job and a role applies to the current staffing crisis in long-term care.What would staff say if they were asked what they do at your facility? Would they respond with their title and job description? I’m a nurse. I work nights. I do admissions. I order supplies. I pass meds. I organize activities. I drive patients to appointments. I’m a manager. I take care of residents on the 100 hall. I clean rooms. Just like the first stonecutter, they list their job duties.Or would the staff share their role in the facility? I belong on a team dedicated to improving the quality of life for people who live here.The difference between a job and a role is that a person with a role has a purpose. Beginning to understand what creates a sense of purpose for individual staff members can help define their roles within the team.Three: Business as Usual Versus Meeting Human NeedsIf we are going to transform nursing homes into rewarding and joyful places to work, places where people are paid fairly and have the resources they need to step fully into their roles, we need to cultivate communities with a sense of purpose: in which each person, no matter his or her job description, is part of a team. We need to shift from thinking about the facility as a mere business (run by extrinsic motivations such as financial reward and star ratings) to an organization that also meets the human needs of both residents and staff. We need to continually strive to meet our needs for contribution, belonging, community, and purpose, and rebuild our nursing homes together as organizations that co-hold business and human needs.Ms. Hector is a clinical educator, national speaker, and associate editor and member of the Editorial Advisory Board for Caring for the Ages. “Purpose is not about what we do and how fast we do it; but why we do it, and how we do it.”Paolo Gallo The pandemic catapulted the post-acute and long-term care environment into multiple crises simultaneously, which made caring for our most vulnerable community members a monumental endeavor. The bandages of a largely dysfunctional system have been ripped off, and we are figuring out how to stem the bleeding long enough to create a functional health care system that not only serves the people who need care but also the caregivers themselves. As Professor David Grabowski has said, “We’ve overlooked and undervalued this workforce for a long time, and now we’re at a full-blown crisis” (Skilled Nursing News, Mar. 10, 2022, https://bit.ly/36kCeem). In response, many leaders are trying to find meaningful ways to support staff well-being with strategies that include increased pay, extra paid days off, cards reading “I’ll be back in 15 minutes” to give staff permission to take breaks, employee-of-the-day recognition, thank-you cards for staff who have done nice things, and food — lots of food. But when the meal is over, the card is read, and the employee returns after a paid day off, has anything changed? Or is the facility culture still “business as usual”? Although these extrinsic strategies are welcomed and enjoyed by staff, they fall short of what’s needed to strengthen staff well-being and, ultimately, retention. According to a webinar hosted by the Gerontological Society of America, even if a facility eliminates the influencing factors that lead to turnover, it doesn’t that mean staff will stay (“Common Data Elements for Workforce and Staffing in International Long-Term Care Research,” Sept. 3, 2020, https://www.youtube.com/watch?v=qLdcdeUxhUs). This is in part because, despite all positive efforts, the staff still are being pushed to accomplish an ever-growing list of tasks on top of their job descriptions, and they go home feeling discouraged, resentful, exhausted, and numb. Contributing to this crisis is a phenomenon called the “just-get-over-it culture,” where health care staff are expected to adapt quickly to changing circumstances and not spend time processing their emotions (M. Goulston and D. Hendel, Why Cope When You Can Heal, Harper Horizon, 2020). But human beings are not meant to function by ignoring their physical and emotional needs while being pushed to work harder and faster no matter the cost to their well-being. We can continue to treat people as “human resources” — viewing them as materials we obtain, shape, use, then throw away (as described by Del Nelson in Henry Neave, The Deming Dimension, SPC Press, 1990) — or we can choose differently. Choosing DifferentlyAccording to Davis Balestracci, an individual’s perception of the work environment is crucial (“Data ‘Sanity’: Statistical Thinking Applied to Everyday Data,” Medical Group Management Association, 2015). If staff’s perception is that they do not matter or that they do not belong, that is their daily reality. And what’s more, that perception influences the leadership’s reality as well. Balestracci teaches the concept of “bolted-on” versus “built-in” culture. Bolted-on cultures eventually rattle loose and fall off, risking staff frustration and, worse, cynicism. Built-in cultures are sustainable, woven into the facility cultural fabric.How can we create a built-in culture that makes PALTC staff want to stay? The following are a few thought shifts that we can make to the ways that we perceive the problem in order to affect the ways that we see the solution. They will help us move from bolted-on strategies to built-in strategies. According to Davis Balestracci, an individual’s perception of the work environment is crucial (“Data ‘Sanity’: Statistical Thinking Applied to Everyday Data,” Medical Group Management Association, 2015). If staff’s perception is that they do not matter or that they do not belong, that is their daily reality. And what’s more, that perception influences the leadership’s reality as well. Balestracci teaches the concept of “bolted-on” versus “built-in” culture. Bolted-on cultures eventually rattle loose and fall off, risking staff frustration and, worse, cynicism. Built-in cultures are sustainable, woven into the facility cultural fabric. How can we create a built-in culture that makes PALTC staff want to stay? The following are a few thought shifts that we can make to the ways that we perceive the problem in order to affect the ways that we see the solution. They will help us move from bolted-on strategies to built-in strategies. One: Extrinsic Versus Intrinsic MotivationWe can choose to create facility cultures where intrinsic motivation can thrive, forgoing extrinsic motivational factors like stars, rewards, and the looming fear of discipline. Intrinsic motivation is entirely different than doing something out of fear, competition, or being shamed with discipline. Intrinsic motivation is driven by human needs for purpose, fun, learning, belonging, self-knowledge, and passion. When we do things because we genuinely love to, we bring our full self to the experience. Working with staff to understand and create intrinsic motivation is an important part of the process. We can choose to create facility cultures where intrinsic motivation can thrive, forgoing extrinsic motivational factors like stars, rewards, and the looming fear of discipline. Intrinsic motivation is entirely different than doing something out of fear, competition, or being shamed with discipline. Intrinsic motivation is driven by human needs for purpose, fun, learning, belonging, self-knowledge, and passion. When we do things because we genuinely love to, we bring our full self to the experience. Working with staff to understand and create intrinsic motivation is an important part of the process. Two: Job Versus RoleYou may recall the story of two stonecutters: when asked what they are doing, the first says, “I’m cutting this stone into blocks,” and the second says, “I’m on a team building a cathedral.” Similarly, this difference between a job and a role applies to the current staffing crisis in long-term care.What would staff say if they were asked what they do at your facility? Would they respond with their title and job description? I’m a nurse. I work nights. I do admissions. I order supplies. I pass meds. I organize activities. I drive patients to appointments. I’m a manager. I take care of residents on the 100 hall. I clean rooms. Just like the first stonecutter, they list their job duties.Or would the staff share their role in the facility? I belong on a team dedicated to improving the quality of life for people who live here.The difference between a job and a role is that a person with a role has a purpose. Beginning to understand what creates a sense of purpose for individual staff members can help define their roles within the team. You may recall the story of two stonecutters: when asked what they are doing, the first says, “I’m cutting this stone into blocks,” and the second says, “I’m on a team building a cathedral.” Similarly, this difference between a job and a role applies to the current staffing crisis in long-term care. What would staff say if they were asked what they do at your facility? Would they respond with their title and job description? I’m a nurse. I work nights. I do admissions. I order supplies. I pass meds. I organize activities. I drive patients to appointments. I’m a manager. I take care of residents on the 100 hall. I clean rooms. Just like the first stonecutter, they list their job duties. Or would the staff share their role in the facility? I belong on a team dedicated to improving the quality of life for people who live here. The difference between a job and a role is that a person with a role has a purpose. Beginning to understand what creates a sense of purpose for individual staff members can help define their roles within the team. Three: Business as Usual Versus Meeting Human NeedsIf we are going to transform nursing homes into rewarding and joyful places to work, places where people are paid fairly and have the resources they need to step fully into their roles, we need to cultivate communities with a sense of purpose: in which each person, no matter his or her job description, is part of a team. We need to shift from thinking about the facility as a mere business (run by extrinsic motivations such as financial reward and star ratings) to an organization that also meets the human needs of both residents and staff. We need to continually strive to meet our needs for contribution, belonging, community, and purpose, and rebuild our nursing homes together as organizations that co-hold business and human needs.Ms. Hector is a clinical educator, national speaker, and associate editor and member of the Editorial Advisory Board for Caring for the Ages. If we are going to transform nursing homes into rewarding and joyful places to work, places where people are paid fairly and have the resources they need to step fully into their roles, we need to cultivate communities with a sense of purpose: in which each person, no matter his or her job description, is part of a team. We need to shift from thinking about the facility as a mere business (run by extrinsic motivations such as financial reward and star ratings) to an organization that also meets the human needs of both residents and staff. We need to continually strive to meet our needs for contribution, belonging, community, and purpose, and rebuild our nursing homes together as organizations that co-hold business and human needs. Ms. Hector is a clinical educator, national speaker, and associate editor and member of the Editorial Advisory Board for Caring for the Ages.

Central MessageA well-developed plan, mentorship, good attitude, and hard work are the recurring themes for early-career success in cardiothoracic surgery.PerspectiveThe leap from cardiothoracic trainee to practicing surgeon is one of the most challenging in one's career. The Thoracic Surgery Resident Association identified several individuals who have demonstrated early-career success after this transition to learn their keys to success. We provide a concise summary of this information for all trainees preparing for this transition.The Thoracic Surgery Resident Association (TSRA) organized a webinar series entitled “Bridging the Gap: Tips for Early-Career Success in Cardiothoracic Surgery,” focused on strategies for early-career success in cardiothoracic surgery. Each of these 6 sessions was moderated by a TSRA Executive Committee member and featured early-career surgeons who have recently transitioned into practice and demonstrated success in integrating new techniques or clinical focus. Topics included robotic cardiac surgery, congenital surgery, atrial fibrillation surgery, thoracic surgery, transplant and heart failure, as well as structural heart.The TSRA Executive Committee, in a multistep process, selected the early-career surgeons for the webinar series. We first identified the 6 topics most important to trainees preparing to transition into practice. Next, we solicited nominations for junior faculty that, in the view of TSRA members, embodies successful transition to practice based on clinical volume, outcomes, and reputation. The TSRA Executive Committee then voted on individuals for each session, and they were invited to participate with a 100% invite acceptance rate.Robotic Cardiac SurgeryThe first episode in this series focused on robotic cardiac surgery and featured a discussion with Dr Gianluca Torregrossa, a clinical associate of surgery at the University of Chicago, and Dr Brittany Zwischenberger, an assistant professor of surgery at Duke University. During an excellent discussion moderated by Dr David Blitzer from Columbia University, there were several important points that were emphasized. First, and most importantly, Drs Torregrossa and Zwischenberger emphasized the need to develop extensive experience and confidence with traditional cardiac surgery before attempting to develop robotic experience or a robotic program. Dr Torregrossa specifically recommended working for several years with traditional surgery before pursuing robotic training. Dr Torregrossa described a series of 4 habits that are critical for robotic surgery. First, he recommended gaining experience with the robot in any surgical venue, be it cardiac or gynecologic surgery. Second, he recommended extensive experience with the robot simulator. Third, we were advised to record and review one's robotic cases to search for areas of improvement by oneself or with a mentor. Similarly, his fourth suggestion was to review videos of more-experienced robotic surgeons to discover areas for technical improvement.Once ready to begin a robotic program, Dr Torregrossa described a need for 2 key inputs. The first is mentorship; either within or outside of your institution, from someone who can help train you in robotic surgery and proctor your first cases. When searching for mentorship, Dr Torregrossa recommended searching for someone with diverse robotic experience and a known reputation as an educator. The second key input is support from your institution and department, as developing a successful robotic surgery program is dependent on consistent experience and buy-in from a team that includes nurses, anesthesiologists, partner surgeons, and hospital administrators. Looking to the future, Dr Torregrossa predicted an expanding role for robotic cardiac surgery, as patient preferences are steered toward minimally invasive techniques, but also identified a need for continued innovation with robotic technology and its clinical application. From a trainee perspective, the take-home message from this episode highlights the importance of a dedicated 3- to 5-year plan after cardiothoracic fellowship to begin building a robotic cardiac surgery practice.Early-Career Development in Congenital Cardiac SurgeryThe second episode in the series focused on early-career development and maximizing training opportunities for congenital cardiac surgeons. Dr Elizabeth Stephens, of the Mayo Clinic, and Dr Damien LaPar, of the University of Texas Houston, joined as panelists for a productive discussion moderated by Dr Garrett Coyan, of the University of Pittsburgh. The discussion centered on aspects to consider at all stages of early-career development while pursuing congenital cardiac surgery. Early dedicated mentorship was a consistent theme, as the unique training and apprenticeship-style of an early congenital career requires strong mentorship. Multiple mentors for different aspects (technical skill development, academics/research, and society involvement among others) can be critical, and searching outside the bounds of one's own department and institution can be a useful strategy. Trainees at any stage interested in increasing exposure to congenital cardiac surgery should aggressively pursue mentorship as soon as possible to optimize opportunities for growth within the specialty.Residents should focus on clinical excellence during cardiothoracic surgery residency and especially technical training, as congenital fellowship itself likely will be a time of reduced technical operating volume due to the nature of the specialty and the learning curve. Research and academic work are extremely important during residency to enhance knowledge of the congenital field and become competitive for congenital fellowship training. Following congenital fellowship, early focus on clinical and technical development was stressed as the most important factor for gaining traction out of fellowship, with layering on of research and administrative responsibilities as time progresses. Most early-career congenital surgeons will not feel comfortable with clinical practice for several years, and this is normal due to the variety of cases and stressors from the job. As the process of development takes significant time, the virtue of patience was emphasized by both panelists as a key aspect to a successful career transition. Although the process may be long and daunting, for those who persevere, the clinical practice of congenital cardiac surgery can be extremely rewarding. From a trainee perspective, the take-home message from this episode was that early preparation and planning during training is critical to secure a congenital fellowship position and first job with appropriate mentorship for early-career success in congenital heart surgery.Surgical Treatment of Atrial FibrillationThe third episode was centered on the surgical treatment of atrial fibrillation. The session, moderated by Dr Yihan Lin, from the University of Colorado, featured 2 well-known surgeons in the field: Dr Armin Kiankhooy and Dr Lawrence Lee. Dr Armin Kiankhooy was previously a faculty member at the University of Southern California and is currently in private practice at Adventist Health in Napa Valley, California. Dr Lawrence Lee is currently a cardiac faculty member at the Indiana University and is also the program director of the thoracic residency. These 2 surgeons from very different practice backgrounds were able to provide key insights on how to integrate atrial fibrillation surgery early within a surgeon's practice.This topic was particularly interesting to residents, as specific training for the surgical treatment of atrial fibrillation is not universal in thoracic surgery training programs. In fact, many residents and faculty have to find opportunities outside of their home institution to gain the necessary technical skills. The panelists discussed several compelling reasons to seek this additional training, as well as provided resources for current residents to pursue. They also discussed a stepwise progression of how to start out first as a safe surgeon and then grow into an expert in the field. Dr Lee and Dr Kiankhooy also discussed the practice differences in private practice compared with academics and how to maximize success in atrial fibrillation surgery in each setting. The panelists emphasized that in addition to technical skills, communication with colleagues, especially cardiology and electrophysiology colleagues, is critical. As many of these patients are referred from cardiology, it is important to foster a collaborative culture among the different departments. The session ended with a great suggestion by Dr Kiankhooy: To maximize success, practice the 3 A's: “Available, Affable, Ability.” Be available and visible so your colleagues know you are invested. Be affable so these same colleagues find you approachable. And make sure you have the ability to ensure good outcomes for your patients—and if there is a bad outcome, always communicate this with your referring physician. The take-home message from this episode was the importance of identifying clinical mentorship when adopting additional techniques and building collaborative relationships with referring physicians.Thoracic Surgery Early-Career TipsThis episode featured early-career tips for thoracic surgeons with guest panelists Dr Brian Mitzman, Assistant Professor at Univ of Utah and Director of Robotic Thoracic Surgery, and Dr Joshua Boys, Assistant Professor at University of California San Diego. The session was moderated by Dr Fatima Wilder, MD, from Johns Hopkins University. The primary focus of the discussion was tips for finding your first job. The panelists stressed the importance of using your mentors and taking opportunities to meet people in various settings, including meetings, even if it is in your first year of training. They agreed that cold calls/e-mails are okay and are almost expected. Dr Boys pointed out that fellows, junior attendings, previous faculty, advanced practitioners, and anesthesiology can all offer useful perspective on the places where you are interviewing. In addition, industry reps will offer a third-party perspective. Dr Mitzman pointed out some red flags to watch out for, including a high turnover, a single senior partner who has always been by themselves, not interviewing with a variety of people, lack of a solid plan for you, and an unclear reimbursement structure. Everyone agreed that self-education is important in contract negotiation and finance management and recommended finding a financial advisor who knows the physician's life/trajectory as well as planning for disability insurance. Participants were also encouraged to talk to faculty about what they did and what resources they used as well as checking the MGMA (Medical Group Management Association) data to understand regional standards for compensation! Everyone agreed that reasonable things to negotiate for include moving expenses, signing bonuses, and tuition reimbursement. Importantly, if you are promised research, be sure to get things delineated in your contract, such as protected time, where funding will come from, etc. Dr Boys reminded participants to do every case you can while you're still a trainee and get the basic skills so you can put them together when you need to. Dr Mitzman stressed that robotics is important, but don't neglect your open and video-assisted thoracoscopic surgery skills or foregut. Once starting your first job, communication is key (with colleagues, your significant other, partners, etc). If you're not happy, be honest with yourself and find a solution. If you need to leave before 5 years, it's OK! Hold on to and keep in touch with your mentors! The take-home message from this episode was a roadmap for applying and securing your first job out of fellowship.Early-Career Tips in Transplant and Heart FailureDr Marisa Cevasco, from the Hospital of the University of Pennsylvania, and Dr Amy Fiedler, from the University of Wisconsin, joined the session as 2 recently graduated attending surgeons who are leading active practices in the field of mechanical circulatory support (MCS) and heart transplantation (HT). Both surgeons emphasized being drawn early on to the subspecialty due to its tremendous impact on patients' lives, as well as the multidisciplinary and innovative nature of the practice. Moreover, the spectrum of dynamic physiology across the population with heart failure is remarkable and requires more than just technical mastery. Practically speaking regarding one's first job coming out of training, both surgeons stated that the scope of one's practice will vary with the needs of the practice and may align well with performing high-risk coronary artery bypass grafting or mitral valve operations. It is important to be busy and to be given the opportunity to perform about 150 “bread-and-butter” pump cases in addition to MCS or HT cases during the first year in a job, so one can develop the necessary operative skills and autonomy. Whatever the case, Dr Fiedler advised trainees to be introspective, thoughtful, and honest about the desired career trajectory.Completing a super-fellowship was viewed as a beneficial, but not a required, experience if one is very intentional about gaining experiences in this subspecialty early on and can find adequate mentorship during the transition to being an attending. Also, both surgeons shared that it is possible to practice in both academic institutions and private practices that are large and can support the full clinical spectrum; therefore, pursuing MCS or HT does not commit you to a specific archetype. Additional nuanced considerations included how the MCS and HT teams are structured and workflow is arranged. At some institutions, cardiologists take donor calls, whereas at others, cardiac surgeons do. Having a strong and inclusive relationship with heart failure cardiologists is incredibly important, and one has to be cognizant of how the culture may be variable across institutions. Some institutions have established multidisciplinary rounding structures, which can be clinically beneficial, given that patients with heart failure are seldom on a simple “pathway” and require constant oversight and communication to get them through. Regarding work–life balance, being a MCS or HT surgeon certainly presents challenges in this domain, such as dealing with a more complex and less-elective population, often requiring you to operate all night or during the weekend on a relatively short notice. However, if one is passionate about the field, these circumstances are also what makes the field exceptionally rewarding. The most important thing is to understand who you are and what makes you tick; and if it happens to be MCS and HT, one can look forward to a meaningful career. The take-home message from this episode was the importance of case volume, clinical mentorship, and a collaborative heart failure program in early-career success as a HT/MCS surgeon.Developing a Career in Structural HeartThe final installment of the early-career webinar series is one focused on structural heart disease featuring a discussion with Dr Anson Cheung, from the University of British Columbia, Dr Ibrahim Sultan, from the University of Pittsburgh, Dr Tsuyoshi Kaneko, from Harvard University Brigham and Women's Hospital, and Dr Isaac George, from Columbia University. Key themes of discussion revolved around the role of the surgeon in structural heart disease, education, competency, and potential accreditation for the niche, and the importance of how to cultivate and sustain a healthy heart team.Panelists collectively cited that technology, mentorship, and the ability to offer all aspects of treatment for patients with valvular disease, whether that is open or minimally invasive surgical procedures as well as transcatheter-based techniques, and providing a balanced view of valvular intervention were the driving reasons for pursuing a niche in structural heart disease. In terms of the role of the surgeon in structural heart disease, panelists felt that it comes down to the individual and one's goals in practice. There are minimal case volume requirements as per the American Board of Thoracic Surgery, but currently there lacks specific accreditation in structural heart disease for surgeons and cardiologists (which may come down the pipeline soon). As such, this inevitably lends itself to surgeons having varied levels of competence and exposure in structural heart disease—with expert versus nonexpert surgeons. They discuss that as a specialty, we need to address the following question: is the goal to ensure that all surgeons are able to perform transcatheter aortic valve replacements (TAVRs), or are we trying to train select individuals to serve as transcatheter specialists? If yes to the former, then TAVR should be integrated into the training paradigm, and if yes to the latter, then transcatheter training should be a dedicated fellowship. Panelists felt that there should be a baseline level of competence for surgeons in structural heart disease—to be amenable to be a functional member of the Heart Team, to have an understanding of the language, the core concepts, basic wire skills, and be able to make rational decisions, but not necessarily the need to do every part of the procedure every time. Graduating cardiothoracic surgery trainees should be able to perform all aspects of transfemoral TAVR as a basic competence, with further advanced skills such as alternative access, transcatheter valve-in-valve, mitral, or tricuspid procedures more of a fellowship-based skill or for those with dedicated focus toward structural heart disease. The importance of strong collaboration with the Heart Team (cardiac surgeon, cardiologist, interventional cardiologist, heart failure cardiologist, echocardiologist, nurses) cannot be understated, with various structures of the Heart Team described. Ultimately, all panelists stressed the need for surgeons to see the patients, be present at rounds and at the table advocating for what one believes in. The Heart Team is a relationship among all specialties involved; it needs to be mutual, treasured, with time invested toward cultivating the Team for the benefit of patients. From a trainee perspective, the take-home message from this episode was the importance of keeping up with the rapidly evolving technology, taking an active role in procedures, and investing time/effort in the heart Team collaboration.ConclusionsThe Early-Career Webinar series is another TSRA initiative to meet our mission to provide peer-based resources and support for cardiothoracic surgery residents to succeed throughout training and launch successful careers. We have highlighted several recurring themes that presenters felt were critical to early-career success (Table 1). The sessions were well attended, with approximately 100 live trainee viewers and more than 500 YouTube views of the recorded sessions. Similarly, the information provided during the webinars was disseminated through social media, including 43,976 Tweet impressions (unique views), 1625 Facebook views, and 1180 LinkedIn views. The TSRA is excited to offer this new opportunity to cardiothoracic surgery trainees around the world and will keep the webinars available through the TSRA YouTube channel (https://www.youtube.com/channel/UCyjU49Z1w88buh9g5sL-ImA).Table 1Thoracic Surgery Residents Association Early-Career Development Series pearlsMentorship from experienced individuals in the fieldSponsorship and support from individuals outside your department or institutionThoughtful patience when dealing with obstacles to your ideal practice in the first few yearsCommunication with partners, colleagues, and collaborators to ensure successful relationshipsTechnical ability is important, and every case in training is a learning opportunityKnow yourself and be honest about your career aspirationsYou must be a present and active member of the team to have your voice heard Open table in a new tab A well-developed plan, mentorship, good attitude, and hard work are the recurring themes for early-career success in cardiothoracic surgery. A well-developed plan, mentorship, good attitude, and hard work are the recurring themes for early-career success in cardiothoracic surgery. The leap from cardiothoracic trainee to practicing surgeon is one of the most challenging in one's career. The Thoracic Surgery Resident Association identified several individuals who have demonstrated early-career success after this transition to learn their keys to success. We provide a concise summary of this information for all trainees preparing for this transition. The leap from cardiothoracic trainee to practicing surgeon is one of the most challenging in one's career. The Thoracic Surgery Resident Association identified several individuals who have demonstrated early-career success after this transition to learn their keys to success. We provide a concise summary of this information for all trainees preparing for this transition. The Thoracic Surgery Resident Association (TSRA) organized a webinar series entitled “Bridging the Gap: Tips for Early-Career Success in Cardiothoracic Surgery,” focused on strategies for early-career success in cardiothoracic surgery. Each of these 6 sessions was moderated by a TSRA Executive Committee member and featured early-career surgeons who have recently transitioned into practice and demonstrated success in integrating new techniques or clinical focus. Topics included robotic cardiac surgery, congenital surgery, atrial fibrillation surgery, thoracic surgery, transplant and heart failure, as well as structural heart. The TSRA Executive Committee, in a multistep process, selected the early-career surgeons for the webinar series. We first identified the 6 topics most important to trainees preparing to transition into practice. Next, we solicited nominations for junior faculty that, in the view of TSRA members, embodies successful transition to practice based on clinical volume, outcomes, and reputation. The TSRA Executive Committee then voted on individuals for each session, and they were invited to participate with a 100% invite acceptance rate. Robotic Cardiac SurgeryThe first episode in this series focused on robotic cardiac surgery and featured a discussion with Dr Gianluca Torregrossa, a clinical associate of surgery at the University of Chicago, and Dr Brittany Zwischenberger, an assistant professor of surgery at Duke University. During an excellent discussion moderated by Dr David Blitzer from Columbia University, there were several important points that were emphasized. First, and most importantly, Drs Torregrossa and Zwischenberger emphasized the need to develop extensive experience and confidence with traditional cardiac surgery before attempting to develop robotic experience or a robotic program. Dr Torregrossa specifically recommended working for several years with traditional surgery before pursuing robotic training. Dr Torregrossa described a series of 4 habits that are critical for robotic surgery. First, he recommended gaining experience with the robot in any surgical venue, be it cardiac or gynecologic surgery. Second, he recommended extensive experience with the robot simulator. Third, we were advised to record and review one's robotic cases to search for areas of improvement by oneself or with a mentor. Similarly, his fourth suggestion was to review videos of more-experienced robotic surgeons to discover areas for technical improvement.Once ready to begin a robotic program, Dr Torregrossa described a need for 2 key inputs. The first is mentorship; either within or outside of your institution, from someone who can help train you in robotic surgery and proctor your first cases. When searching for mentorship, Dr Torregrossa recommended searching for someone with diverse robotic experience and a known reputation as an educator. The second key input is support from your institution and department, as developing a successful robotic surgery program is dependent on consistent experience and buy-in from a team that includes nurses, anesthesiologists, partner surgeons, and hospital administrators. Looking to the future, Dr Torregrossa predicted an expanding role for robotic cardiac surgery, as patient preferences are steered toward minimally invasive techniques, but also identified a need for continued innovation with robotic technology and its clinical application. From a trainee perspective, the take-home message from this episode highlights the importance of a dedicated 3- to 5-year plan after cardiothoracic fellowship to begin building a robotic cardiac surgery practice. The first episode in this series focused on robotic cardiac surgery and featured a discussion with Dr Gianluca Torregrossa, a clinical associate of surgery at the University of Chicago, and Dr Brittany Zwischenberger, an assistant professor of surgery at Duke University. During an excellent discussion moderated by Dr David Blitzer from Columbia University, there were several important points that were emphasized. First, and most importantly, Drs Torregrossa and Zwischenberger emphasized the need to develop extensive experience and confidence with traditional cardiac surgery before attempting to develop robotic experience or a robotic program. Dr Torregrossa specifically recommended working for several years with traditional surgery before pursuing robotic training. Dr Torregrossa described a series of 4 habits that are critical for robotic surgery. First, he recommended gaining experience with the robot in any surgical venue, be it cardiac or gynecologic surgery. Second, he recommended extensive experience with the robot simulator. Third, we were advised to record and review one's robotic cases to search for areas of improvement by oneself or with a mentor. Similarly, his fourth suggestion was to review videos of more-experienced robotic surgeons to discover areas for technical improvement. Once ready to begin a robotic program, Dr Torregrossa described a need for 2 key inputs. The first is mentorship; either within or outside of your institution, from someone who can help train you in robotic surgery and proctor your first cases. When searching for mentorship, Dr Torregrossa recommended searching for someone with diverse robotic experience and a known reputation as an educator. The second key input is support from your institution and department, as developing a successful robotic surgery program is dependent on consistent experience and buy-in from a team that includes nurses, anesthesiologists, partner surgeons, and hospital administrators. Looking to the future, Dr Torregrossa predicted an expanding role for robotic cardiac surgery, as patient preferences are steered toward minimally invasive techniques, but also identified a need for continued innovation with robotic technology and its clinical application. From a trainee perspective, the take-home message from this episode highlights the importance of a dedicated 3- to 5-year plan after cardiothoracic fellowship to begin building a robotic cardiac surgery practice. Early-Career Development in Congenital Cardiac SurgeryThe second episode in the series focused on early-career development and maximizing training opportunities for congenital cardiac surgeons. Dr Elizabeth Stephens, of the Mayo Clinic, and Dr Damien LaPar, of the University of Texas Houston, joined as panelists for a productive discussion moderated by Dr Garrett Coyan, of the University of Pittsburgh. The discussion centered on aspects to consider at all stages of early-career development while pursuing congenital cardiac surgery. Early dedicated mentorship was a consistent theme, as the unique training and apprenticeship-style of an early congenital career requires strong mentorship. Multiple mentors for different aspects (technical skill development, academics/research, and society involvement among others) can be critical, and searching outside the bounds of one's own department and institution can be a useful strategy. Trainees at any stage interested in increasing exposure to congenital cardiac surgery should aggressively pursue mentorship as soon as possible to optimize opportunities for growth within the specialty.Residents should focus on clinical excellence during cardiothoracic surgery residency and especially technical training, as congenital fellowship itself likely will be a time of reduced technical operating volume due to the nature of the specialty and the learning curve. Research and academic work are extremely important during residency to enhance knowledge of the congenital field and become competitive for congenital fellowship training. Following congenital fellowship, early focus on clinical and technical development was stressed as the most important factor for gaining traction out of fellowship, with layering on of research and administrative responsibilities as time progresses. Most early-career congenital surgeons will not feel comfortable with clinical practice for several years, and this is normal due to the variety of cases and stressors from the job. As the process of development takes significant time, the virtue of patience was emphasized by both panelists as a key aspect to a successful career transition. Although the process may be long and daunting, for those who persevere, the clinical practice of congenital cardiac surgery can be extremely rewarding. From a trainee perspective, the take-home message from this episode was that early preparation and planning during training is critical to secure a congenital fellowship position and first job with appropriate mentorship for early-career success in congenital heart surgery. The second episode in the series focused on early-car

JTCVS Open

Feb 22, 2022
Yihan Lin + 8

ObjectiveTo explore obstetrics patients' experiences with telemedicine during COVID-19 and assess their intent for its future use. DesignAn exploratory design was applied considering that telemedicine was a new phenomenon in Pakistan particularly for antenatal care services during COVID-19. MethodPrimary data was collected through a telephonic survey of 132 respondents randomly selected from the pool of obstetrics patients who used telemedicine services of Shifa International Hospital (SIH) in Islamabad, Pakistan during the pandemic. We changed the survey tool of Medical Group Management Association to the study purpose. Required information included the respondents’ socioeconomic and antenatal characteristics and their telemedicine use experience on four parameters, namely, Appointment, Staff Attitude, Communication, and Telemedicine Services. Patients were inquired about their intent to use telemedicine beyond COVID-19 and the reasons supporting their answer. The data was analyzed descriptively and through t-test mean comparisons and binary logistic regression. ResultsMajority (54%) intend to use telemedicine in future. Average age of respondents was 30 years with gravidity 2.36, parity 1.40 and gestational amenorrhea 27.3 weeks. The respondents average schooling was 9.5 years, marriage duration was 4.5 years and monthly household income was PKR ∼83,000. However, the overall experience of those who were confident in future use of telemedicine was 0.677 points higher and significantly different than those who were not inclined to use it in future. Of those lacking interest in future use of telemedicine, nearly two-third felt in-person visit was more satisfying, 11% needed physical examination, ∼6% experienced long waiting time, 5% each had inadequate access to ICT and online payment facilities, and 6% faced other issues such as excess payments. The binary logistic regression analysis (R2 37.3%) held Medical Consultations and Communications as the most important determinants and could predict nearly two-fifth of variation in respondents’ intent for future use of telemedicine. ConclusionUptake of telemedicine for obstetrics patients is one of the positive externalities of COVID-19 and may appear as a cost-effective and culturally acceptable way to ensure universal coverage of antenatal care in Pakistan. However, telemedicine’s future beyond COVID-19 for obstetrics hinges upon improving users’ experience primarily through consultant and staff trainings and provision of effective communication e.g., in regional languages. Besides, offering physical examination facility and ability to use mobile wallet payment solutions may motivate future use of telemedicine in obstetrics.

BackgroundOn December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations. MethodsA mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs). ResultsAll modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases. ConclusionThe impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon’s operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload.

Much of the Affordable Care Act (ACA) and subsequent US health care policies were designed to address deficiencies in health care access and enhance primary care services. How residency positions and physician incomes have changed in the post-ACA era is not well characterized. We evaluated the growth of US trainee positions and physician income, in the pre- vs post-ACA environment by specialty and among primary care vs specialty care. Total resident complement by specialty and year was extracted from the National Graduate Medical Education (GME) Census and stratified into primary care vs specialty care. Median incomes were extracted from Medical Group Management Association surveys. Piecewise linear regression with interaction terms (pre-ACA, 2001-2010, vs post-ACA, 2011-2019) assessed growth rate by specialty and growth rate differences between primary care and specialty care. Sensitivity analyses were performed by focusing on family medicine and excluding additional GME positions contributed by the introduction of the 2015 single GME accreditation system. Resident complements increased for primary care (+0.16%/year pre-ACA to +2.06%/year post-ACA, P < .001) and specialty care (+1.49%/year to +2.07%/year, P = .005). Specialty care growth outpaced primary care pre-ACA (P < .001) but not post-ACA (P = .10). Family medicine had the largest increase in the pre- vs post-ACA era (-0.77%/year vs +2.09%/year, P < .001). Excluding positions contributed by the single GME accreditation system transition did not result in any statistically significant changes to the findings. Income growth increased for primary care (+0.84%/year to +1.37%/year, P = .044), but decreased for specialty care (+1.44%/year to +0.49%/year, P = .011). Specialty care income growth outpaced primary care pre-ACA (P < .001), but not post-ACA (P = .22). We found significant growth differences in resident complement and income among primary care versus specialty care in the pre-/post-ACA eras.

The Merit-based Incentive Payment System (MIPS) is a major Medicare value-based purchasing program, influencing payment for more than 1 million clinicians annually. There is a growing concern that MIPS increases administrative burden, and little is known about what it costs physician practices to participate in the program. To examine the costs for independent physician practices to participate in MIPS in 2019. This qualitative study identified and interviewed leaders of physician practices participating in the US Centers for Medicare & Medicaid Services (CMS) MIPS program, including those in MIPS alternative payment models. Time required and financial costs were calculated from responses to in-depth, semistructured interviews conducted from December 12, 2019, to June 23, 2020. Physician practices were categorized by size (small, 1-9 physicians; medium, 10-25; and large, ≥50), specialty (primary care, general surgery, or multispecialty), and US census region. Participants were asked about 2019 costs related to clinician and staff time, information technology, and external vendors. Time was converted to financial costs using the Medical Group Management Association's Provider Compensation and the Management and Staff Compensation databases. Annual time spent by staff on MIPS-related activities and mean per-physician costs to physician practices in 2019. Leaders of 30 physician practices (9 [30.0%] small primary care, 6 [20.0%] small general surgery, 4 [13.3%] medium primary care, 4 [13.3%] medium general surgery, and 7 [23.3%] large multispecialty) represented all US census regions, and 14 of the 30 (46.7%) practices participated in a MIPS alternative payment model in 2019. The mean per-physician cost to practices of participating in MIPS was $12 811 (interquartile range [IQR], $2861-$17 715). Physicians, clinical staff, and administrative staff together spent 201.7 (IQR, 50.9-295.2) hours annually per physician on MIPS-related activities. Medical assistants and nursing staff together spent a mean of 99.2 (IQR, 0-163.3) hours per physician each year; frontline physicians spent 53.6 (IQR, 0.6-55.8) hours; executive administrators spent 28.6 (IQR, 3.1-26.7) hours; other clinicians and staff spent a combined 20.3 (IQR, 0-36.8) hours. Physician time accounted for the greatest proportion of overall MIPS-related costs (54%; $6909; IQR, $94-$9905). In this qualitative study, physician practice leaders reported significant time and financial costs of participating in the MIPS program. Attention to reducing the burden of MIPS may be warranted.

BackgroundMedicare’s Merit-based Incentive Payment System (MIPS) is a major value-based purchasing program. Little is known about how physician practice leaders view the program and its benefits and challenges.ObjectiveTo understand practice leaders’ perceptions of MIPS.Design and ParticipantsInterviews were conducted from December 12, 2019, to June 23, 2020, with leaders of 30 physician practices of various sizes and specialties across the USA. Practices were randomly selected using the Medical Group Management Association’s membership database. Practices included small primary care and general surgery practices (1–9 physicians); medium primary care and general surgery practices (10–25 physicians); and large multispecialty practices (50 or more physicians). Participants were asked about their perceptions of MIPS measures; the program’s effect on patient care; administrative burden; and rationale for participation.Main MeasuresMajor themes related to practice participation in MIPS.Key ResultsInterviews were conducted with 30 practices representing all US census regions. Six major themes emerged: (1) MIPS is understood as a continuation of previous value-based payment programs and a precursor to future programs; (2) measures are more relevant to primary care practices than other specialties; (3) leaders are conflicted on whether the program improves patient care; (4) MIPS creates a substantial administrative burden, exacerbated by annual programmatic changes; (5) incentives are small relative to the effort needed to participate; and (6) external support for participation can be helpful. Many participants indicated that their practice only participated in MIPS to avoid financial penalties; some reported that physicians cared for fewer patients due to the program’s administrative burden.ConclusionsPractice leaders reported several challenges related to MIPS, including irrelevant measures, administrative burden, frequent programmatic changes, and small incentives. They held mixed views on whether the program improves patient care. These findings may be useful to policymakers hoping to improve MIPS.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06758-w.

Introduction Resident physicians have a professional degree but are compensated less than other recently graduated professionals such as lawyers or nurse practitioners. The U.S. Military Healthcare System differs from the civilian setting in that physicians' salaries are based primarily on military rank. We compared military and civilian physician salaries across various specialties to determine if the increased military pay during residency compensates for military attending physicians' lower income as compared to their civilian counterparts.MethodsThis cross-sectional study compares military and civilian pay for resident and attending physicians in the fields of Obstetrics & Gynecology (OB/GYN), Family Medicine, and General Surgery. Military pay was obtained from 2018 Defense Finance and Accounting Service (DFAS) data. Civilian salaries were obtained from the Medscape 2018 Residents Salary & Debt Report, Medical Group Management Association (MGMA) 2018 Provider Compensation Report, and 2017-2018 Association of American Medical Colleges (AAMC) Faculty Salary Report.ResultsMilitary resident physicians earned 53% more than civilian residents while military attending physicians earned 32%-58% less (after taxes) than their civilian counterparts, varying by specialty. Military attending physicians' negative pay differential occurred in both academic and non-academic practice environments through MGMA data.DiscussionThe positive pay differential in military residency does not compensate for the negative pay differential of military attending physicians face as compared to their civilian counterparts. This negative pay differential persisted when comparing post-tax pay. Some military service benefits, such as decreased educational debt, are challenging to quantify and vary considerably between individuals. As the military seeks to reshape its healthcare force, military and civilian compensation differences should be considered.

The growth and promulgation of Advanced Practice Providers (APPs) across the entire spectrum of healthcare delivery has been profound, and APPs are increasingly common members of emergency department (ED) care teams. Emergency APP workforce growth is outpacing that of emergency physicians with little to suggest that this trend will subside. The evolution of the deployment of APPs in emergency care has been dramatic; initially, emergency APPs were deployed to lower acuity patients or environments-minor injury and illness and in conjunction with an emergency physician-hence the now antiquated description of APPs as "physician extenders."

The cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents. A personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident's on-call economic value. A single on-call neurosurgical resident at the authors' institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually. Neurosurgery residents at the authors' institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.

This survey study uses data from the Medical Group Management Association’s voluntary physician compensation survey from 2008 to 2017 to examine trends in compensation for primary care and specialist physicians after passage of the Affordable Care Act.

Concern regarding the adequacy of the vascular surgery workforce persists. We aimed to predict future vascular surgery workforce size and capacity using contemporary data on the US population and number, productivity, and practice patterns of vascular surgeons. The workforce size needed to maintain current levels of access was estimated to be 1.4 vascular surgeons/100,000 population. Updated population estimates were obtained from the US Census Bureau. We calculated future vascular surgery workforce needs based on the estimated population for every 10 years from 2020 to 2050. American Medical Association Physician Masterfile data from 1997 to 2017 were used to establish the existing vascular surgery workforce size and predict future workforce size, accounting for annual rates of new certificates (increased to an average of 133/year since 2013), retirement (17%/year), and the effects of burnout, reduced work hours, transitions to nonclinical jobs, or early retirement. Based on Medical Group Management Association data that estimate median vascular surgeon productivity to be 8,481 work relative value units (wRVUs)/year, excess/deficits in wRVU capacity were calculated based on the number of anticipated practicing vascular surgeons. Our model predicts declining shortages of vascular surgeons through 2040, with workforce size meeting demand by 2050. In 2030, each surgeon would need to increase yearly wRVU production by 22%, and in 2040 by 8%, to accommodate the workload volume. Our model predicts a shortage of vascular surgeons in the coming decades, with workforce size meeting demand by 2050. Congruence between workforce and demand for services in 2050 may be related to increases in the number of trainees from integrated residencies combined with decreases in population estimates. Until then, vascular surgeons will be required to work harder to accommodate the workload. Burnout, changing practice patterns, geographic maldistribution, and expansion of health care coverage and utilization may adversely affect the ability of the future workforce to accommodate population needs.

The landscape for academic endocrinology divisions has continued to evolve rapidly;thus, finding reliable data that can be used as benchmarks has become more difficult. Resources are available for salary and relative value units, with the Association of American Medical Colleges, Medical Group Management Association, and Faculty Practice Solutions Center the most commonly used databases. However, details regarding how these data are collected and what they include are unclear. For example, does the income include bonus and/or incentive payments? How are work relative value units defined (individual rendering vs supervising advanced practitioners or fellows or residents)? How is a clinical full-time equivalent defined? In addition, other important data that would be relevant to running an academic division of endocrinology are not available from these, or any other resources, including support staff numbers and compensation or fellowship funding and training information. Therefore, an unmet need exists for reliable data that divisions can use to help shape their visions and goals. To address this demand, the Association of Endocrine Chiefs and Directors, in collaboration with the Endocrine Society, developed a detailed survey for members to address the financial, productivity, composition, and educational issues that they regularly face. Twenty academic institutions throughout the United States completed in the survey in 2018. In the present report, we have provided the results of the survey and some initial interpretations of the findings. Our hope is that the information presented will prove useful as academic endocrinology divisions continue to evolve.

In an effort to curb the “madness of data insanity” in health care, a presentation at the 2018 AMDA – the Society for Post-Acute and Long-Term Care Medicine Annual Conference challenged the attendees to consider a different approach to statistics, one that emphasizes statistical thinking. Leonard Gelman, MD, and I offered attendees a vibrant discourse on the complexity and the simplicity of improvement statistics, and showed how they can be best deployed in our facilities. The basis of this session was the work of statistician Davis Balestracci, the author of Data Sanity, 2nd ed. (Englewood, CO: Medical Group Management Association, 2015). A fundamental principle of statistical thinking, which is a philosophy of learning and action, is the view of systems as interconnected processes. Because variation exists in all such processes, understanding and reducing that variation is the key to successful change. In our current environment, nursing homes face incredible pressure: demands for “accountability,” complicated payment models, and extensive regulations as well as publicly reported data and tragedies. Unfortunately, many facilities and corporations are stuck in a whack-a-mole mindset — reacting to each incident as it pops up. Also, like most health care organizations, nursing home staff are obsessed with alleged “statistics” in the form of bar charts, rankings, arbitrary goals, and trends. Too often these data are incorrectly presented in traffic-light format, with red, yellow, and green delineations. In our presentation, I pointed out the difficulties created by these erroneous graphical displays and the detrimental impact of their vague problems, data, questions, solutions, and results. I challenged the attendees to consider how much money and time is being wasted on in-service training based on vague data and inappropriate data displays. Dr. Gelman gave a brief review of quality assurance and process improvement (QAPI) and explained the difference between quality assurance (QA) and performance improvement (PI). QA is regulatory compliance and focuses on outliers. PI is the ongoing effort to meet consumer needs and focuses on process breakdowns and finding hidden opportunities for improvement. Both components are necessary for a successful QAPI program. Each month in QAPI meetings across the nation staff come prepared with reams of data, poised to compare the numbers in the current month with the last month, the last quarter, or the same time last year. Simply comparing two numbers can yield nothing efficaciously actionable — yet the whack-a-mole mentality takes over. The leadership will look at vague graphical displays, circle the numbers they are either happy or unhappy about, and say, “Falls are too high — what is staff doing wrong?” Or “We have too many readmissions — I’m disappointed.” Or “There are fewer pressure ulcers this month — great job!” The staff get reprimanded for the “unhappy” numbers and directed to do better next month, or they are rewarded with a pizza party to celebrate the “happy” numbers. This is the wrong approach. It only adds to the complexity of working in the post-acute and long-term care setting. Why do we collect data? This is where statistical theory becomes critical: the purpose of data is to predict. And prediction is not an explanation but a basis for action. Predicting how much money to spend, what to spend it on, which staff configurations are the best to meet patient needs, and where to focus improvement efforts is paramount for every nursing home. These predictions must be based on knowledge — an understanding of the data and the processes that produced them, and how to analyze that data to predict the next steps. Statistical theory is a basis for process improvement. Theory provides meaning to our experiences, and it gives us a direction for appropriate actions. Just like the theories that guide medical practice, the theory of variation guides process improvement. Properly identifying, interpreting, and acting on the type of variation that is a creating a problem is the key to sustainable improvement. Recognizing variation as a basic statistical concept was the emphasis of our session, and Dr. Gelman and I demonstrated theory in action by teaching the use of run and control charts, the importance of data collection using falls and complaints as our examples, and the pitfalls of root cause analyses as they are traditionally done. As is typical in most nursing homes, leadership uses predominately results-oriented thinking to make decisions about improvement. Results-oriented thinking occurs when facility staff take action based on their perception of what a data point means (for instance, “too many falls”) — think of this as knee-jerk action, or crisis mode. The better alternative to crisis mode is process-oriented thinking as a foundation for sustainable improvement. This type of thinking is based on the fact that everything we do is a process: a sequence of tasks that transform an input into an output. Assessing a patient, writing an order, transcribing the order, and following the order are a series of tasks that are part of an overall process. Unfortunately, processes rarely operate smoothly, and there is a gap between what should happen and what actually happens in the facility. This gap is called variation, a key concept in improvement theory. To improve performance in any area, you must first understand what outcome the process is perfectly designed to produce. If we skip that important step, the result is time and money wasted in staff meetings trying to justify why this month’s numbers are more or less than last month’s (or last quarter’s, or last year’s) when the process itself has not changed. There are pitfalls of arbitrary goals, also known as “management by objectives” or “management by results.” Arbitrary goals abound in nursing homes. The leadership decides that there should only be X number or percentage of some metric, and they set that as a goal without understanding what the process is capable of achieving. Arbitrary goals are deceptive because they are established without a framework of statistical theory. It’s tempting to think, “If we got that number once, we can do it again.” Facility leadership make a grave mistake when they focus on reducing (or increasing) a number and not on improving the process that produced that number. As William Edwards Deming, an engineer and statistician, put it, “Sure we want good results. But if you manage by results, quality goes down, morale does down.” We are not suggesting that goals should be eliminated — only that arbitrary goals should be. So rather than asking why the numbers are different (“Why are there more falls this month?”), we should engage the staff in a collaborative dialogue: “What did we do differently that may have increased falls this month?” This focuses instead on the process that caused the number. Again, statistical theory is the key to achieving process improvement. Instead of business as usual where facilities focus on one or two data points, we encouraged our session attendees to engage their staff in productive dialogue: “We don’t want to reduce/increase some metric — we want to improve the process that created that metric.” To that end, choosing the correct improvement strategy is crucial for a successful and sustainable intervention. Too often, staff jump to a solution that is complicated by a poor understanding of how the process works and a lack of good baseline data. Or the staff may choose the most aggressive data strategy — a performance improvement project that disrupts the facility’s culture and precipitates staff resentment. Strategies for improving on an existing, stable process (common cause variation) should follow a plan: 1) exhaust the in-house data, 2) stratify the data, 3) disaggregate the data, and 4) formally design an experiment. This is the “Check, Analyze, Plan, Do” (CAP-Do) or “Plan, Do, Study, Act” (PDSA) cycle. • Strategy 1, Exhaust the in-house data. Facilities already collect enormous amounts of data, so we start there, by creating run charts to collect baseline information. In this stage we will ask lots of questions to better understand the processes that produced the data. Keep in mind that no changes are going to be made based on this baseline data — the goal at this point is to gain insight into the process and to identify better data collection methods.Strategy 1, Exhaust the in-house data. Facilities already collect enormous amounts of data, so we start there, by creating run charts to collect baseline information. In this stage we will ask lots of questions to better understand the processes that produced the data. Keep in mind that no changes are going to be made based on this baseline data — the goal at this point is to gain insight into the process and to identify better data collection methods.• Strategy 2, Stratification. Data collected from any stable period (common cause variation) is combined at this stage. For example, rather than just looking at the falls from one month, we will combine many months or even several years, and then we stratify the data. Stratification is simply separating the data into different groups: day of the week, type of incident, location, age, diagnosis, and so on. The staff has already been stratifying data — but now they’ll be doing it within a framework, and with knowledge of the theory of variation.Strategy 2, Stratification. Data collected from any stable period (common cause variation) is combined at this stage. For example, rather than just looking at the falls from one month, we will combine many months or even several years, and then we stratify the data. Stratification is simply separating the data into different groups: day of the week, type of incident, location, age, diagnosis, and so on. The staff has already been stratifying data — but now they’ll be doing it within a framework, and with knowledge of the theory of variation. An excellent tool to help stratify data is the Pareto Matrix. This tool is based on the principle that 20% of the process inputs are causing 80% of the problems (again, think variation). The Pareto Matrix helps to find the hidden opportunities for improvement. • Strategy 3, Disaggregation. When we disaggregate the process, we dissect the entire process into subprocesses , and we focus on specific aspects to achieve the most improvement. Think about the Pareto Matrix here, and about identifying those 20% of the inputs that are causing 80% of the problems. Truly, this stage gives you the most bang for your buck!Strategy 3, Disaggregation. When we disaggregate the process, we dissect the entire process into subprocesses, and we focus on specific aspects to achieve the most improvement. Think about the Pareto Matrix here, and about identifying those 20% of the inputs that are causing 80% of the problems. Truly, this stage gives you the most bang for your buck! Using falls as our example, the data may show clusters of falls happening in different locations in the facility. The post-acute unit may have process inputs that result in a higher number of ambulatory falls; the secured unit for residents living with dementia may have process inputs that result in a high number of falls from wheelchairs. By engaging in the correct improvement strategy, in the proper order, the facility’s leadership can identify where to focus the improvement work and exactly what type of help each unit needs. Because the data clearly indicate that different processes are at work in different locations, trying to apply one type of intervention to all units and all staff no longer occurs. Disaggregation guides conscious decision-making based on improvement theory. • Strategy 4, Experiment or intervention . Only after we have engaged in the other three strategies, in the correct order, do we proceed to directly addressing the process. Interventions and experiments take considerable time and resources, so they should not be undertaken casually.Strategy 4, Experiment or intervention. Only after we have engaged in the other three strategies, in the correct order, do we proceed to directly addressing the process. Interventions and experiments take considerable time and resources, so they should not be undertaken casually. Dr. Gelman summarized our session and emphasized the importance of getting all of the staff to think about their work as composed of processes, not just series of tasks. Thinking more deeply about the waste that occurs every day in every facility, making better choices, and having conversations based on statistical theory are critical steps in achieving sustainable improvement. Ms. Hector speaks at health care conferences on end-of-life care, clinical operations for the interprofessional team, process improvement and statistical theory, documentation and care plans. She is a member of the Annual Conference Program Planning Committee for AMDA – the Society for Post-Acute and Long Term Care Medicine, a member of the Editorial Advisory Board for Caring, and the Chair for the Spring Conference Planning Committee for the Arizona Geriatrics Society. Dr. Gelman, past president of the Society, is the medical director of Indian River Nursing Home, Granville, NY.

INTRODUCTION: Disparities exist between resident salaries and other professionals. We compared salaries to determine if military pay equalizes financial disparities in civilian graduate medical education training. METHODS: Using aggregate salary data, we compared military versus civilian salaries for residents and staff physicians in OB/GYN. Military pay was from 2017 Defense Finance and Accounting Service (DFAS) tables, including: base pay, housing/subsistence allowances, incentive and board certification pay. Military residents were calculated for O-3, and staff salaries the average of O-4 and O-5. Civilian salaries were from Medscape 2016 Residents Salary & Debt Report, Medical Group Management Association (MGMA) 2017 Provider Compensation Report for private practice, and from 2015-2016 Association of American Medical Colleges (AAMC) Faculty Salary Report for academic providers, using the rank of Assistant Professor. RESULTS: The GME salary gap was positive, with mean civilian OB/GYN residents $55,000, compared to military residents $91,287, +66% difference. For staff, the salary gap is negative, with mean private practice $368,135 and mean academic $277,000 compared to military $163,099, -56% and -42% respectively. For subspecialists in OB/GYN, the military is $168,099 compared to private practice UROGYN $422,413 (-$60%); private practice REI $427,667 (-60%) academic REI $392,000 (-57%); private practice GYN/ONC $486,118 (-65%) academic GYN/ONC $323,600 (-50%); private practice MFM $536,279 (-69%) academic MFM $339,700 (-52%). CONCLUSION: A salary gap exists in the military, shifting from positive in residency to negative for staff. The gap is smaller for academic faculty compared to private practice. Actual salaries vary based on multi-year bonuses and scholarship programs that decrease debt.

ObjectiveResidents often make career decisions regarding future practice without adequate knowledge to the realities of professional life. Currently there is a paucity of data regarding economic differences between practice models. This study seeks to illuminate the financial differences of surgical subspecialties between academic and private practice. DesignData were collected from the Association of American Medical College (AAMC) and the Medical Group Management Association’s (MGMA) 2015 reports of average annual salaries. Salaries were analyzed for general surgery and 7 subspecialties. Fixed time of practice was set at 30 years. Assumptions included 5 years as assistant professor, 10 years as associate professor, and 15 years as full professor. Formula used: (average yearly salary) × [years of practice (30 yrs − fellowship/research yrs)] + ($50,000 × yrs of fellowship/research) = total adjusted lifetime revenue. ResultsAs a full professor, academic surgeons in all subspecialties make significantly less than their private practice counterparts. The largest discrepancy is in vascular and cardiothoracic surgery, with full professors earning 16% and 14% less than private practitioners. Plastic surgery and general surgery are the only 2 disciplines that have similar lifetime revenues to private practitioners, earning 2% and 6% less than their counterparts′ lifetime revenue. ConclusionsAcademic surgeons in all surgical subspecialties examined earn less lifetime revenue compared to those in private practice. This difference in earnings decreases but remains substantial as an academic surgeon advances. With limited exposure to the diversity of professional arenas, residents must be aware of this discrepancy.

Medical Group Management Association Research Articles

Articles published on Medical Group Management Association

From Debt to Dollars: Assessing a General Surgeon's Career Value

Comparison of Calculations of the Financial Impact of Fellowship Training by Data Source

EDITORIAL COMMENT

Optimizing Care Teams by Leveraging Advanced Practice Providers Through Strategic Workforce Planning.

Do Staff in Your Facility Have a Job or a Role?

Insights from the thoracic surgery residents association early-career development series

Beyond COVID-19: Prospect of telemedicine for obstetrics patients in Pakistan

The 2021 Centers for Medicare and Medicaid Services Fee Schedule’s Impact on Adult Reconstruction Surgeon Productivity and Reimbursement

US Primary Care vs Specialty Care Trainee Positions and Physician Incomes: Trends From 2001 to 2019.

Time and Financial Costs for Physician Practices to Participate in the Medicare Merit-based Incentive Payment System: A Qualitative Study.

Physician Practice Leaders' Perceptions of Medicare's Merit-Based Incentive Payment System (MIPS).

Comparing Compensation of U.S. Military Physicians and Civilian Physicians in Residency Training and Beyond.

The Economics and Effectiveness of Advanced Practice Providers Are Decidedly Local Phenomena.

The economic value of an on-call neurosurgical resident physician.

Trends in Compensation for Primary Care and Specialist Physicians After Implementation of the Affordable Care Act

An Updated Physician Workforce Model Predicts a Shortage of Vascular Surgeons for the Next 20 Years

Compensation, Productivity, and Other Demographics of Academic Divisions of Endocrinology, Diabetes, and Metabolism.

The Power of Process Improvement

Graduate Medical Education Salary Gap: Is Military Service an Equalizing Force? [4C]

The Economics of Private Practice versus Academia in Surgery

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