Advanced practice providers in hematology: actionable findings from national paired APP and physician surveys.

ABSTRACT: Advanced practice providers (APPs) are critical to the hematology workforce. However, there is limited knowledge about APPs in hematology regarding specialty-specific training, scope of practice, challenges and opportunities in APP-physician interactions, and involvement with the American Society of Hematology (ASH). We conducted APP and physician focus groups to elucidate major themes in these areas and used results to inform development of 2 national surveys, 1 for APPs and 1 for physicians who work with APPs. The APP survey was distributed to members of the Advanced Practitioner Society of Hematology and Oncology, and the physician survey was distributed to physician members of ASH. A total of 841 APPs and 1334 physicians completed the surveys. APPs reported most hematology-specific knowledge was obtained via on-the-job training and felt additional APP-focused training would be helpful (as did physicians). Nearly all APPs and physicians agreed that APPs were an integral part of their organizations and that physician-APP collaborations were generally positive. A total of 42.1% of APPs and 29.3% of physicians reported burnout, and >50% of physicians felt that working with APPs had reduced their burnout. Both physicians and APPs reported interest in additional resources including "best practice" guidelines for APP-physician collaboration, APP access to hematology educational resources (both existing and newly developed resources for physicians and trainees), and greater APP integration into national specialty-specific professional organizations including APP-focused sessions at conferences. Professional organizations such as ASH are well positioned to address these areas.

Telehealth Use and Access to Care for Underserved Populations Before and During the COVID-19 Pandemic.

While several studies have documented the rapid growth in telehealth visits during the pandemic, none have examined its relationship with greater overall access to care among vulnerable populations. We use Association of American Medical Colleges' Consumer Survey data to examine the relationship between access to care and telehealth use before and during the pandemic. The proportion of survey respondents who were always able to get medical care when needed was slightly lower in 2020 compared with prior years while telehealth use rose dramatically. Disparities in telehealth use for Medicaid beneficiaries and rural respondents disappeared during the pandemic, but remained for lower-income populations. Before the pandemic, telehealth use was associated with greater access, but not during the pandemic-when it appears to have become a substitute for in-person. After the pandemic, telehealth could once again be an opportunity to supplement access to care, if telehealth policies enacted during the pandemic are made permanent.

Primary Care Provider Medicaid Participation Across the United States, 2016.

PURPOSE: To understand primary care provider participation in Medicaid programs across states and provider specialties and professions. METHODS: We examined the 2016 Medicaid claims data across 45 states and territories from the Transformed Medicaid Statistical Information System (T-MSIS). RESULTS: Of the 616,182 primary care providers we identified, 111,152 (18.0%) saw no Medicaid patients, 88,723 (14.4%) providers saw one to 10 Medicaid patients, 163,806 (26.6%) saw 11 to 100 Medicaid patients, and 252,501 (41.0%) saw more than 100 Medicaid patients in 2016. The proportion of providers who saw more than 100 Medicaid patients ranged from 22.9% in Virginia to 56.1% in New Mexico. Medicaid participation also differed by specialty, from 78.4% among pediatricians to 61.2% among nurse practitioners. This study lays the foundations for using T-MSIS data to identify communities at the highest risk for access barriers and support targeted policy responses.

Changes in Waivered Clinicians Prescribing Buprenorphine and Prescription Volume by Patient Limit.

This study uses data from a Drug Enforcement Administration list of Drug Addiction Treatment Act (DATA)­waivered clinicians to examine trends in DATA-waivered clinicians' active participation in prescribing buprenorphine overall and by patient limits between January 2017 and May 2021.

Documenting a Decade of Exponential Growth in Employer Demand for Peer Support Providers.

The past decade has seen peer support providers increasingly incorporated as part of a recovery-oriented approach to behavioral health (BH) services for mental illness and substance use disorder. Despite this, there are few data sources to track this sector of the BH workforce, and understanding of peer support provider supply, demand, distribution, and associated factors is limited. In this retrospective, observational study, the authors analyzed job postings from 2010 to 2020 to assess employer demand for peer support providers and the factors associated with its growth, using a labor market data set from Emsi Burning Glass. The authors identified peer support job postings using a three-pronged, stepwise approach. Then, bivariate regression analyses using robust standard errors were conducted to examine state-level relationships between the number of peer support job postings per 100,000 population and Medicaid policies and indicators of states' BH infrastructure. The authors identified approximately 35,000 unique postings, finding the number increased 17-fold between 2010 and 2020. Bivariate analysis found significant state-level associations between peer support job postings and Medicaid expansion, as well as states' mean number of mental health facilities. This analysis represents the first to quantify employer demand for peer support providers, clearly demonstrating robust growth over time. Findings underscore the importance of continuing to develop data on this workforce to better understand factors driving its growth.

Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support.

Burnout is prevalent throughout medicine. Few large-scale studies have examined the impact of physician compensation or clinical support staff on burnout among hematologists and oncologists. In 2019, the American Society of Hematology conducted a practice survey of hematologists and oncologists in the AMA (American Medical Association) Masterfile; burnout was measured using a validated, single-item burnout instrument from the Physician Work-Life Study, while satisfaction was assessed in several domains using a 5-point Likert scale. The overall survey response rate was 25.2% (n = 631). Of 411 respondents with complete responses in the final analysis, 36.7% (n = 151) were from academic practices and 63.3% (n = 260) from community practices; 29.0% (n = 119) were female. Over one-third (36.5%; n = 150) reported burnout, while 12.0% (n = 50) had a high level of burnout. In weighted multivariate logistic regression models incorporating numerous variables, compensation plans based entirely on relative value unit (RVU) generation were significantly associated with high burnout among academic and community physicians, while the combination of RVU + salary compensation showed no significant association. Female gender was associated with high burnout among academic physicians. High advanced practice provider utilization was inversely associated with high burnout among community physicians. Distinct patterns of career dissatisfaction were observed between academic and community physicians. We propose that the implementation of compensation models not based entirely on clinical productivity increased support for women in academic medicine, and expansion of advanced practice provider support in community practices may address burnout among hematologists and oncologists.

Association between state payment parity policies and telehealth usage at community health centers during COVID-19.

OBJECTIVE: We study the association between payment parity policies and telehealth utilization at community health centers (CHCs) before, during, and after the onset of the pandemic. MATERIALS AND METHODS: We use aggregated, de-identified data from FAIR Health for privately insured patients at CHC sites. Descriptive statistics and time trends are calculated. Logistic regression models were used to quantify the factors associated with telehealth utilization for each of our time periods: 1) pre-pandemic (March-June 2019), 2) immediate pandemic response (March-June 2020), and 3) sustained pandemic response (March-June 2021). RESULTS: Telehealth usage rates at CHC sites surged to approximately 61% in April 2020. By April 2021, only 29% of CHC sites in states without payment parity policies used telehealth versus 42% in states without. Controlling for other characteristics, we find that CHC sites in states with payment parity were more likely to utilize telehealth one year after the onset of the pandemic (OR:1.740, p<0.001) than states without, but did not find this association in 2019 or 2020. DISCUSSION: The public health emergency drove widespread use of telehealth, making the virtual care environment inherently different in 2021 than in 2019. Due to the unique fiscal constraints facing CHCs, the financial sustainability of telehealth may be highly relevant to the relationship between telehealth utilization and payment parity we find in this paper. CONCLUSION: Supportive payment policy and continued investments in broadband availability in rural and undeserved communities should enable CHCs to offer telehealth services to populations in these areas.

Does Community College Attendance Affect Matriculation to a Physician Assistant Program? A Pathway to Increase Diversity in the Health Professions.

PURPOSE: To explore whether community college (CC) applicants were a significant contributor to the diversity of matriculants to physician assistant (PA) programs and whether CC applicants were less likely to matriculate to PA programs than non-CC applicants. METHOD: The authors used national data from the 2016-2017 application cycle. They categorized applicants to PA programs into 5 pathways: HS-CC (applicant attended CC while in high school), first-CC (applicant attended CC before a 4-year university), 4Y-CC (applicant attended CC while at a 4-year university), post-CC (applicant attended CC after graduating from a 4-year university), and no-CC (applicant never attended CC). The authors used Pearson chi-square and Kruskal-Wallis H tests and the appropriate post hoc tests to assess whether applicants in the 4 CC pathways were more diverse in terms of their race, ethnicity, gender, rurality, and socioeconomic status than those in the no-CC pathway. They used logistic regressions to assess associations between the CC pathways and matriculation to a PA program. RESULTS: Among the 8,577 matriculants in the 2016-2017 application cycle, more than 75% attended a CC at some point. First-CC and post-CC matriculants were more likely to be Black (P < .001) or Hispanic (P < .001) and come from a disadvantaged background (P < .001) than no-CC matriculants. After adjusting for applicant demographics, academic performance, rurality and socioeconomic status, and application strategy, first-CC applicants had 17% lower odds of matriculating to a PA program than no-CC applicants (P < .001). CONCLUSIONS: CCs are an important pathway to the PA profession, with 3 of 4 matriculants having a CC background. However, lower matriculation rates among similarly qualified applicants who transferred from a CC to a 4-year university than among applicants with no-CC background suggest that PA programs are missing important opportunities for increasing student diversity and thereby the profession.

Advancing Social Mission Research: A Call to Action.

Social mission efforts in health professions education are designed to advance health equity and address the health disparities of the society in which they exist. While there is growing evidence that social mission-related interventions are associated with intended outcomes such as practice in underserved communities, student diversity, and students graduating with skills and knowledge that prepare them to address societal needs, critical evidence gaps remain that limit the possibility of generalizing findings and using social mission strategically to advance health equity. At a time when COVID-19 has been laying bare health disparities related to systemic racism and maldistribution of resources, understanding how health professions training can produce the workforce needed to advance health equity becomes even more imperative. Yet, data and methods limitations are hindering progress in this critical research. The authors present an overview of the social mission research landscape; their review of the research led them to conclude that more rigorous research and data collection are needed to determine the link between social mission activities in health professions education and advances in health equity. To accelerate understanding of how health professions education and training can advance health equity, the authors propose a social mission research road map that includes (1) creating a social mission research community by consolidating stakeholders, (2) building a solid foundation for the research through development of a consensus-driven logic framework and research agenda, and (3) laying out the data and methodological needs that are imperative to strengthening the social mission evidence base and identifying opportunities to address these needs. Core to achieving these milestones is leadership from an organizing body that can serve as a hub for social mission research and engage stakeholder groups in building the evidence base for social mission strategies that will ultimately advance health equity.

A Mixed-Methods Study of Teaching Health Center Residents' Experiences of Mentorship, Career Planning, and Postresidency Practice Environments.

PURPOSE: The Teaching Health Center (THC) Graduate Medical Education program enables primary care physicians to train in community-based, underserved settings by shifting the payment structure and training environment for graduate medical education. To understand how THCs have successfully trained primary care physicians who practice in community-based settings, the authors conducted a mixed-methods exploratory study to examine THC residency graduates' experiences of mentorship and career planning during their residencies, perceptions of preparation for postresidency practice, and how these experiences were related to postresidency practice environments. METHOD: Surveys were conducted for all 804 graduating THC residents nationally, 2014-2017 (533 respondents, 66% response rate). Three quantitative outcomes were measured: graduates' perceptions of preparation for practice after residency (Likert scale), satisfaction with mentorship and career planning (Likert scale), and characteristics of postresidency practice environment (open-ended). A qualitative analysis of open-text survey answers, using thematic content analysis, was also conducted. RESULTS: Most THC graduates (68%) were satisfied with their mentorship and career planning experience and generally felt prepared for postresidency practice in multiple settings (78%-93%). Of the 533 THC graduates who provided information about their practice environment, 445 (84%) were practicing in primary care; nationally, 64% of physicians who completed primary care residencies practiced in primary care. Of the 445 THC graduates practicing in primary care, 12% practiced in rural areas, compared with 7% of all physicians. Just over half of THC graduates (51%) practiced in medically underserved areas, compared with 39% of all physicians. CONCLUSIONS: This study offers early evidence that the THC model produces and retains primary care physicians who are well prepared to practice in underserved areas. Given these promising findings, there appears to be a substantial benefit to growing the THC program. However, the program continues to face uncertainty around ongoing, stable funding.

Coronavirus Disease 2019 Planning and Response: A Tale of 2 Health Workforce Estimator Tools.

BACKGROUND: As coronavirus disease 2019 (COVID-19) rapidly progressed throughout the United States, increased demand for health workers required health workforce data and tools to aid planning and response at local, state, and national levels. OBJECTIVE: We describe the development of 2 estimator tools designed to inform health workforce planning for COVID-19. RESEARCH DESIGN: We estimated supply and demand for intensivists, critical care nurses, hospitalists, respiratory therapists, and pharmacists, using Institute for Health Metrics and Evaluation projections for COVID-19 hospital care and National Plan and Provider Enumeration System, Provider Enrollment Chain and Ownership System, American Hospital Association, and Bureau of Labor Statistics Occupation Employment Statistics for workforce supply. We estimated contact tracing workforce needs using Johns Hopkins University COVID-19 case counts and workload parameters based on expert advice. RESULTS: The State Hospital Workforce Deficit Estimator estimated the sufficiency of state hospital-based clinicians to meet projected COVID-19 demand. The Contact Tracing Workforce Estimator calculated the workforce needed based on the 14-day COVID-19 caseload at county, state, and the national level, allowing users to adjust workload parameters to reflect local contexts. CONCLUSIONS: The 2 estimators illustrate the value of integrating health workforce data and analysis with pandemic response planning. The many unknowns associated with COVID-19 required tools to be flexible, allowing users to change assumptions on number of contacts and work capacity. Data limitations were a challenge for both estimators, highlighting the need to invest in health workforce data and data infrastructure as part of future emergency preparedness planning.

The Use of Medical Scribes in Primary Care Settings: A Literature Synthesis.

BACKGROUND: Clerical burdens have strained primary care providers already facing a shifting health care landscape and workforce shortages. These pressures may cause burnout and job dissatisfaction, with negative implications for patient care. Medical scribes, who perform real-time electronic health record documentation, have been posited as a solution to relieve clerical burdens, thus improving provider satisfaction and other outcomes. OBJECTIVE: The purpose of this study is to identify and synthesize the published research on medical scribe utilization in primary care and safety net settings. RESEARCH DESIGN: We conducted a review of the literature to identify outcomes studies published between 2010 and 2020 assessing medical scribe utilization in primary care settings. Searches were conducted in PubMed and supplemented by a review of the gray literature. Articles for inclusion were reviewed by the study authors and synthesized based on study characteristics, medical scribe tasks, and reported outcomes. RESULTS: We identified 21 publications for inclusion, including 5 that examined scribes in health care safety net settings. Scribe utilization was consistently reported as being associated with improved productivity and efficiency, provider experience, and documentation quality. Findings for patient experience were mixed. CONCLUSIONS: Published studies indicate scribe utilization in primary care may improve productivity, clinic and provider efficiencies, and provider experience without diminishing the patient experience. Further large-scale research is needed to validate the reliability of study findings and assess additional outcomes, including how scribes enhance providers' ability to advance health equity.

Associations between hematology/oncology fellows' training and mentorship experiences and hematology-only career plans.

As the adult hematology and oncology fellowship training pathways have merged in the United States and concerns have arisen about the aging of practicing hematologists, the American Society of Hematology and hematology education leaders are looking to improve their understanding of the factors that contribute to fellows' plans to enter hematology-only careers. With the support of the American Society of Hematology, we collected and analyzed data from a survey of hematology/oncology fellows (n = 626) to examine the relationship between training and mentorship experiences and fellows' plans to enter hematology-only careers. Fellows who planned to enter hematology-only careers were significantly more likely to report having clinical training and mentorship experiences in hematology throughout their training relative to fellows with oncology-only or combined hematology/oncology career plans. After controlling for prior interest in hematology and demographic characteristics, exposure to hematology patients in medical school and fellowship, hematology research experiences, and hematology mentorship (research collaboration and career coaching) were positively and significantly associated with hematology-only career plans. These findings suggest that increasing opportunities for exposure to hematology patients, research opportunities and mentors throughout training could be helpful in building a strong pipeline of potential hematologists.

The Role of the National Health Service Corps Clinicians in Enhancing Staffing and Patient Care Capacity in Community Health Centers.

OBJECTIVE: The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs. METHODS: Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care. RESULTS: Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians. CONCLUSIONS: The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

Are State Telehealth Policies Associated With The Use Of Telehealth Services Among Underserved Populations?

Using four years of data from a nationally representative consumer survey, we examined trends in telehealth usage over time and the role state telehealth policies play in telehealth use. Telehealth use increased dramatically during the period 2013-16, with new modalities such as live video, live chat, texting, and mobile apps gaining traction. The rate of live video communication rose from 6.6 percent in June 2013 to 21.6 percent in December 2016. However, underserved populations-including Medicaid, low-income, and rural populations-did not use live video communication as widely as other groups did. Less restrictive state telehealth policies were not associated with increased usage overall or among underserved populations. This study suggests that state efforts alone to remove barriers to using telehealth might not be sufficient for increasing use, and new incentives for providers and consumers to adopt and use telehealth may be needed.

Alternative payment models lead to strategic care coordination workforce investments.

BACKGROUND: Care coordination is generally viewed as a key to success for health systems seeking to adapt to a range of new value-based payment policies. PURPOSE: This study explores care coordination staffing in four health systems participating in new payment models, including Medicaid payment reform and Accountable Care Organizations. METHODS: Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff at four health systems engaged in value-based contracts. DISCUSSION: Each of the sites engaged in significant task shifting of low-complexity care coordination activities to licensed practical nurses, medical assistants, and other unlicensed personnel freeing up registered nurses and social workers for more complex patients. Few have care coordination experience, requiring a significant investment in on-the-job training. CONCLUSION: Payment reform is leading to a greater investment in the care coordination workforce. However, demonstrating the return on investment remains a challenge.