WAPA News

Expanding the Primary Care Workforce
Center for American Progress Report Highlights Role of PAs
A November 2009 report, “Expanding the Primary Care Workforce,” recommends that the U.S maximize the current primary care workforce through better use of nurse practitioners and physician assistants, saying that “the primary care shortage requires us to maximize the use
of every health care professional to the full extent of their training
and competency.” Read more

Special Message from State Health Officer Dr. Hayes on us of Antivirals

Hospitals Referring More Disruptive Physicians to the Washington Physicians Health Program
By Jean Colley

This article was reprinted with permission from the February 2009 issue of WSMA Reports.

Over the last four to five years, hospital leaders in Washington state and elsewhere have experienced a change in how aggressively they deal with physicians behaving less than professionally.  The pace of change accelerated last July when the Joint Commission issued a “sentinel event alert” announcing that beginning January 1 hospitals must have a code of conduct defining “disruptive and inappropriate behaviors” by all health professionals, 
including physicians, and hospital leaders must implement a process for addressing disruptive behaviors by any employee.  The alert prompted hospitals across the state to refer disruptive physicians to the Washington Physicians Health Program for confidential evaluation and treatment. (The WPHP helps physicians impaired by alcohol, drugs, or any other physical or mental condition.)

The WPHP had been receiving about one such a referral a month, but in the months since the alert, it has been receiving one referral a week.  “Hospitals have become exquisitely sensitive to the issue of disruptive physician behavior,” said Mick Oreskovich, MD, CEO of the WPHP .

“Instead of just relying on general policies, they recognize they must look at people who are the root cause of the problem.”  Referral to WPHP typically comes after multiple incident reports and after informal and formal meetings between the disruptive physician and hospital leaders have failed to lead to a change in behavior. (See sidebar on steps to a referral to WPHP .) Smaller hospitals may be more likely to refer to WPHP because they lack the in-house expertise to handle disruptive physicians. “Most of the referrals show a pervasive pattern,” said Dr. Oreskovich. “We are seeing a lot of people who had been problematic for a long time.” Most physicians referred to the WPHP are younger men practicing subspecialties that involve procedures.  They have exhibited repeated outbursts of anger by shouting or throwing objects, criticized other staff in front of peers, other staff or patients, or written critical personal comments about other staff in the chart.

Physicians referred to WPHP for disruptive behavior generally do not have substance abuse problems. If they have been accused of sexual misconduct, they are referred directly to the Medical Quality Assurance Commission. One surgeon threw clamps and needle holders at team members in the operating room. He later admitted that he’d done that a few times, and yes, he’d used profanity and raised his voice, but it was only because they weren’t paying attention. He didn’t see a problem with that. The hospital medical staff executive committee finally ordered him to go to the WPHP for a psychiatric evaluation or lose his OR privileges. He was diagnosed with a depressive disorder and prescribed medications and psychotherapy in his home community. He eventually learned how to ask for what he needed in the OR without frightening his co-workers and has returned to work. Disruptive physicians with depression or bipolar disorder respond most quickly to treatment, said Dr. Oreskovich. Those who need coaching or mentoring may need years of help, but most do respond positively in time. In the last two years, WPHP has had only two-three cases in which practitioners lost their privileges—and their livelihood— because they failed to respond to treatment.  Not surprisingly physicians referred for disruptive behavior aren’t happy about it. Said Dr. Oreskovich, “They simmer quite a while before they get grateful. Initially, they are very angry at the way this process occurred and angry  at having to go see WPHP . It takes a while before they can see their own responsibility in it, much more than physicians referred for chemical dependency.” Despite concerns by many physicians, Dr. Oreskovich has not seen any cases that were clearly retaliatory. “That doesn’t mean it is not going to happen, but in our experience, the concern is unsubstantiated.”

What’s behind the bad behavior? Tensions between hospitals and medical staffs have increased in the last few years over how physicians practice in hospitals. Physicians who have traded independent practice for hospitalist positions have had to give up autonomy and agree to oversight of their practice patterns and scope of practice in return for regular hours and a steady salary. Which tests to order and which medications to prescribe are now parts of a hospital policy, not the physician’s personal judgment. Surgeons don’t have control over who works with them in the operating room from day today.  “The landscape has changed,” said Dr. Oreskovich.  “That change has increased physicians’ stress and unfortunately, lots of physicians have maladaptive coping styles. They expect the institution to change, when the only thing that can change is their attitude and their response. Instead of coming up with workable solutions to what they see as problems they start making demands. We know that making demands doesn’t work very well, and this puts them in conflict.”  Society has very high expectations of the quality of care. “We as patients all expect the best possible care, and we get very upset when it isn’t perfect” he said.  “Physicians not only expect perfection from themselves but from everybody else involved with care. Physician expectations of perfection can become toxic. A lot of the time, physicians begin taking potshots at coworkers or the administration.  They don’t realize it changes the milieu when they are too critical or too irritable. It put patients at risk because it affects communication within the team.” 

The Joint Commission leadership standard requires the entire medical staff to demonstrate core competencies in interpersonal skills and professionalism and understand effective conflict resolutions strategies. With a concerted educational effort and committed leaders, Dr. Oreskovich is optimistic that the problem of disruptive physician behavior may actually not be a long-lasting problem, at least to the degree it is now. 

Health care organizations that ignore disruptive behaviors by hospital staff expose themselves to litigation from both employees and patients, according to the Joint Commission. Studies link patient complaints about unprofessional, disruptive behaviors and malpractice risk. The commission notes that several surveys have found that most care providers have experienced or witnessed intimidating or disruptive behaviors. 

What to do…  The WSMA recommends that all disruptive physician policies be incorporated into the medical staff bylaws, reviewed by independent legal counsel and voted on by the active medical staff. WSMA is updating its model medical staff bylaws, which will include a model disruptive behavior policy.  If you are a WSMA member you can contact Tim Layton, JD, WSMA Director of Legal Affairs, at tim@wsma.org.

To view the Joint Commission sentinel event alert cited in this article, go to www.jointcommission.org/  SentinelEvents/SentinelEventAlert/sea_40.htm.

For more on the WPHP , go to www.wphp.org/.

King County Public Health Reserve Corps (PHRC)
My name is Kevin Lawson, I am an AmeriCorps Vista volunteering with King County Public Health. Specifically in Public Health the Reserve Corps (PHRC), a group of both medical and non-medical volunteers that are prepared to augment the King County health system and Public Health staff during an emergency. Our main goal is to have pre-screened/pre-trained volunteers to call upon in case of a major health disaster (such as an earthquake or pandemic flu). In a sense, we are creating a registry of volunteer personnel to accelerate their implementation into our disaster response. A group like this will greatly increase our ability to quickly and effectively respond to any future disaster.

Currently we are gearing up to launch our big PHRC recruitment campaign with transit ads, direct mail, and in person recruitment strategies (i.e. recruitment fairs, etc.). We have made contacts with several medical associations throughout the state in search of methods to get information out to their members. We also have worked very closely with local colleges and other organizations to fill various non-medical roles. One group of volunteers we need is physician assistants. Attached are two documents, one is a general information flyer, while the other is an Op-Ed on the PHRC. More information is available on our website at (http://www.metrokc.gov/health/).

As for the PHRC, it is a very minimum requirement volunteer position only requiring the completion of a 3 hour orientation, two online FEMA courses as well as BBP training, but plays a vital role if activated during an emergency. Applying is very easy online. Liability is covered by the state. If you think of any method that we could utilize to get our information out to your members about filling this position please let me know. Some examples include a link on your website, annual conferences we can attend, newsletters, ect. Thank you very much for your help.

Kevin Lawson, AmeriCorps King County Public Health Vista
Public Health Reserve Corps
Public Health- Seattle & King County
401 Fifth Avenue, Suite 1300
Seattle, WA 98104
206-263-8034
425-269-4700 cell
Dedicated Volunteers Prepared to Respond!

Congress Fails to Pass Legislation Stopping 10.6% Medicare Physician Payment Cut Going Into Effect July 1
Unfortunately before recessing for the 4th of July, Congress failed to pass legislation which would have halted the 10.6% Medicare Physician payment cut.  Therefore, the cut will go forward as scheduled and will affect services rendered on or after July 1, 2008.  The 1.0 floor on the geographic practice cost indexes (GPCI) also expires, meaning an additional 1%-3% cut for physicians in areas impacted by the GPCI.

Health and Human Services (HHS) Secretary Mike Leavitt issued a statement today, indicating that if after recess Congress is able to pass legislation that President Bush will sign, the Administration will "promptly […] re-process claims and take other steps necessary to ensure that providers and beneficiaries are not negatively affected." In the meantime, physicians should plan to continue submitting claims as usual.

ACTION NEEDED
While Congress is out on recess we ask that you continue putting pressure on your legislators to rectify this unacceptable situation.  Contact your legislators' DC offices using the Alliance of Specialty Medicine's toll-free Grassroots Hotline at 1-866-899-4088. When asked for your 4-digit specialty code, enter 6969.  You may also e-mail your legislators or contact their district office to schedule a visit.  Please contact Nevena Minor, Manager, Legislative Affairs for assistance or with any questions at (202)464-3431 or nminor@HRSonline.org.

Background
As previously reported, on Tuesday the House of Representatives passed by a vote of 355 to 59, HR 6331 "The Medicare Improvements for Patients and Providers Act of 2008". The bill, largely modeled after S. 3101, the Medicare legislation introduced by Senate Finance Committee Chairman Max Baucus (D-MT), would have continued the .5% update to Medicare physician payments for 2008 and provided a 1.1% update through 2009.  It is unclear why so many House Republicans (115) voted for the bill, despite President Bush's veto-threat because of the bill's modifications to Medicare Advantage Plans.  Some speculate that the Republicans were expecting to vote later this week on a compromise package being crafted by Sen. Baucus and Senate Finance Committee Ranking Member Charles Grassley (R-IA), which would have ultimately superseded any House proposal and not likely faced a President veto. Therefore, they may have considered the vote for HR 6331 symbolic to demonstrate their support for physicians and stopping the payment cuts.

Because of the House's overwhelming vote, Sen. Baucus and the Senate Democratic leadership nixed plans to bring up the bi-partisan compromise package, and instead called for a vote to proceed on HR 6331, hoping that the large House Republican support would translate into broad Senate Republican support as well. These hopes however did not materialize when the motion to proceed on the bill failed by 1 vote.  Senate leadership plans to bring the same bill up for another vote after recess. The Society has worked with both sides of the aisle to resolve this urgent issue and will continue urging Congress to reverse this cut and keep you updated on new developments.  

PA's ALLOWED TO DELEGATE TASKS
Health Care Assistants have modified their rules and regulations to allow PA's to delegate tasks or to "give orders to". House Bill 2475 passed in the last legislative session. For more information, go to: www.leg.wa.gov or
http://apps.leg.wa.gov/billinfo/summary.aspx?bill=2475&year=2007

Are you a WAPA member who would like to receive The Monitor by email? If so, contact WAPA.