Thursday, November 15, 2018

Physicians

Physicians
The doctor is in ...

QUALIY/PHYSICIANS: P4P in the United Kingdom

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The biggest P4P scheme in the world is going on in the UK, one that I first wrote about in early 2004. (For more on the  wider ramifications of reform in the UK ,see yet another article in this weeks NEJM

Note that all the GPs there have computers, so they can easily report their process behaviors. Note also that the introduction of the system as done as a way of giving extra cash to GPs, but extra cash for improving quality of primary care process. So the first year’s results are in, and the GPs have done much better than was predicted and better than most American groups studied other than the VA. I think this is so important in the light of where Medcare is going that I’m including the entire discussion section from the NEJM article from the Univ of Manchester group that studied it. It’s called “Pay-for-Performance Programs in Family Practices in the United Kingdom”, and its below the jump, as an exceprt from an article by Arnold Epstein commenting on its implications for the US

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Will Independent Physicians Go Extinct?

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Richard Gunderman goodLife is tough for physicians in solo and small group practice.  The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases.  “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive.  And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians.  In many ways, they affect all physicians alike.  Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues.  Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down –  they are pouring down on the heads of physicians.  Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business.  And the problem is not just the money.  It’s also the time.  Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data.  We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

Two Nations Separated by 5.3 mm

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A popular meme is that the U.S. spends more on healthcare than other developed nations but has nothing to show for that spending. This is different from saying that the U.S. spends more, but achieves something, but the something it achieves is so little that it isn’t worth the public purse. The latter is difficult to assert because the asserter must then say how little is too little in regards to how much is spent, and why. It is easier believing the excess spending has no effect whatsoever, zilch in fact, because this absolves one from having to apply a value judgment on how much a life is worth. This meme, a convenient heuristic, like other convenient heuristics, is wrong.

A recent study looked at trends and outcomes in the management of abdominal aortic aneurysm (AAA) in the U.S. and the U.K. An aneurysm, dilation of the aorta, is more likely to burst the bigger it gets. Aneurysms should be repaired before they rupture because the mortality of ruptured aneurysms can be 50 %. The study, which analyzed several databases that recorded surgery, size of aneurysms, and cause of death, found that Americans repair twice as many aneurysms as the Brits, and the repaired AAAs are smaller, on average, in the U.S. Between 2005-2012 elective AAA repair (i.e. repair of non-ruptured aneurysms) increased from 27 to 32 per 100, 000 in the U.K, and from 58 to 64 per 100, 000 in the U.S.

Dr. Patti Brennan – #SPM2018 speaker preview “Supporting the Care Between the Care: The Role of the National Library of Medicine”

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By ePATIENT DAVE deBRONKART

I’m a supporter of the Society for Participatory Medicine’s second annual conference on Oct. 17 in Boston. This article taken from the SPM “ePatients” blog tells you about just  one of the great speakers who’ll be there. Please come join us  Register here.–Matthew Holt

Dr. Patti Brennan – #SPM2018 speaker preview “Supporting the Care Between the Care: The Role of the National Library of Medicine”

Here’s the latest in our series of posts by and about the outstanding speakers we’ve lined up for the Society for Participatory Medicine’s second annual conference on Oct. 17 in Boston, attached to the prestigious Connected Health conference. Register here. (Our #SPM2018 blog series has more about the speakers and activities.)

Since my earliest days in this work – even before our Society was formed – Dr. Patricia Flatley Brennan RN, PhD, FAAN, FACMI (or “Patti,” as she’s known to her many friends and fans) has been one of the most optimistic voices. She’s always been a dedicated, enlightened researcher, academic (at the University of Wisconsin, Madison) and voice of patient participation. On top of that, she was the director of the Robert Wood Johnson Foundation’s terrific Project HealthDesign: Rethinking the Power and Potential of Personal Health Records, which ran from 2006-2014, an absolutely pivotal period in the onset of personal health data. Patti knows that knowledge is power, and that patient power is naturally optimized when patient knowledge is optimized.

So you can imagine how thrilled I was when, in 2016, she was appointed the next Director of America’s National Library of Medicine (NLM). In addition to being extremely participatory, perhaps it’s no coincidence that she’s the first woman nurse and the first nurse in the post.

In a moment I’ll say more about the history of this position, and its significance in the timeline that led to SPM. For now, consider this about her topic at our conference, “the care between the care,” particularly the NLM’s role.

Rebooting Primary Care From the Bottom Up

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Zubin DamaniaFor the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan…ford).

I used to play a game with the med students and housestaff: let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down—more specialists than primary care docs, really?—we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Worse still, the oppressive weight of our non-system’s dysfunction falls disproportionately on the shoulders of our primary care providers—the very instruments of our potential salvation. To them, there’s little solace (and plenty of administrative intrusion) in the top-down reform efforts of accountable care organizations and “certified” patient-centered medical homes.

But what about a bottom-up, more organic effort to reboot healthcare? A focus on restoring the primacy of human relationships to medicine, empowering patients and providers alike to become potent, positive levers on a 2.8 trillion dollar economy? What if we could spend twice as much on effective, preventative primary care and still pull off a net savings in overall costs, improvements in quality, and increased patient satisfaction?

What if George Lucas had just quit after the original Star Wars series? Wouldn’t the world have been better without Jar Jar Binks?

While the latter question is truly speculative, the former ones aren’t. We’re trying to answer them in Las Vegas (hey now, I’m being serious) at Turntable Health, where we’ve partnered with Dr. Rushika Fernandopulle and Cambridge, MA based Iora Health.

We aim to get primary care right by doing the following:

Milestones or Millstones?

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GundermanGood intentions do not necessarily lead to good results.  A case in point is the milestones initiative of the Accreditation Council of Graduate Medical Education and its various medical specialty boards, which are working together in an attempt to improve the quality of graduate medical education.  In practice, however, the milestones are often not proving to be a valuable indicator of learner progress and are in fact acting like millstones around the necks of trainees and program directors.

The goals behind the milestones initiative are laudable.  Introduced as part of the Next Accreditation System (NAS), they were intended to shift attention of learners and educators from processes to outcomes.  They would foster self-directed learning and assessment and provide more helpful feedback.  In theory, programs that were doing well would face less burdensome oversight and under-performing ones would receive more prompt and helpful guidance.

In practice, however, the milestones initiative has reminded many program directors and trainees of the onerous impact of maintenance of certification programs enacted by the American Board of Medical Specialties.  Simply put, when the lofty rhetoric of initial assurances is set aside, the risks and costs of such initiatives appear to many to exceed the benefits by an unacceptably high margin.  In many cases, this can be traced to a failure to assess outcomes before implementing system-wide change.

Making Sense of the Health Care Merger Scene   

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By JEFF GOLDSMITH

In the past 12 months, there has been a raft of multi-billion-dollar mergers in health care. What do these deals tell us about the emerging health care landscape, and what will they mean for patients/consumers and the incumbent actors in the health system?

Health Systems

There have been a few large health system mergers in the past year, notably the $11 billion multi-market combinations of Aurora Health Care and Advocate Health Care Network in Milwaukee and suburban Chicago, as well as the proposed (but not yet consummated) $28 billion merger of Catholic Health Initiatives and Dignity Health. However, the bigger news may be the several mega-mergers that failed to happen, notably Atrium (Carolinas) and UNC Health Care and Providence St. Joseph Health and Ascension. In the latter case, which would have created a $45 billion colossus the size of HCA, both parties (and Ascension publicly) seemed to disavow their intention to grow further in hospital operations. Ascension has been quietly pruning back their operations in markets where their hospital is isolated, or the market is too small. Providence St. Joseph has been gradually working its way back from a $500 million drop in its net operating income from 2015 to 2016.

Another notable instance of caution flags flying was the combination of University of Pittsburgh Medical Center (UPMC) and PinnacleHealth, in central PA, which was completed in 2017.   Moody’s downgraded UPMC’s debt on the grounds of UPMC’s deteriorating core market performance and integration risks with PinnacleHealth. As Moody’s action indicates, investor skepticism about hospital mega-mergers is escalating. Federal regulators remain vigilant about anti-competitive effects, having scotched an earlier Advocate combination with NorthShore University HealthSystem in suburban Chicago. The seemingly inevitable post-Obamacare march to hospital consolidation seems to have slowed markedly.

However, the most noteworthy hospital deal of the last five years was a much smaller one: this spring’s acquisition of $1.7 billion non-profit Mission Health of Asheville, NC, by HCA. This was remarkable in several respects. First, it was the first significant non-profit acquisition by HCA in 15 years (since Kansas City’s Health Midwest in 2003) and HCA’s first holdings in North Carolina.  While Mission’s search for partnerships may have been catalyzed by a fear of being isolated in North Carolina by the Atrium/UNC combination, Mission Health certainly controlled its own destiny in its core market, with a 50% share of western North Carolina. Mission was not only well managed, clinically strong and solidly profitable, but its profits rose from 2016 to 2017, both from operations and in total.

Feedback Loop

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flying cadeuciiRight now there are two patients in every room. One is made with flesh, bones, and blood. One is made with a monitor, a mouse, and a keyboard.

Both demand my time.

Both demand my concentration.

A little over two weeks ago I wrote the short story Please Choose One. I posted it online. The response it generated exceeded anything I could have ever imagined. It struck a nerve. People contacted me from all over the world, from all walks of life, about the story. Everyone, it seems, can relate to the challenge of having to choose between a person and a screen.

People sent me all kinds of suggestions and ideas. A few sent words of encouragement. Yet, what struck me the most about the people who contacted me was what they did not say. Not a single IT person argued the computer was more important than the patient. Not a single healthcare provider stated they wanted more time with the screen and less time with the patient. And finally, most importantly, not a single patient wrote me and said they wished their doctor or nurse spent more time typing and less time listening.

Medicine is the art of the subtle- the resentful glance from the mother of the newborn presenting with the suspicious bruise, the solitary bead of sweat running down the temple of the fifty three year old truck driver complaining of reflux, the slight flush on the face of the teenage girl when asked if she is having thoughts of hurting herself. These things matter. And these same things are missed when our eyes are on the screen instead of the patient.

How a Physician Can Work With a Not Yet Approved Drug Through Compassionate Use

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Screen Shot 2016-04-18 at 8.05.22 AMIn a time when evidence-based prescribing and clinical guidelines are hot topics in medicine, trying to access a not-yet-approved drug to use in a patient can feel like navigating uncharted waters. Many physicians are unaware that the US Food and Drug Administration (FDA) allows the use of unapproved drugs outside of clinical trials and — even if they did know it is possible — have no idea how to access such investigational drugs for their patients.

This knowledge is largely sequestered into certain clinical specialties, such as oncology or rare disease, and it is not taught in medical school or during residency: instead, is largely self-taught. Thus, while some physicians have become very accustomed to requesting pre-approval access to drugs, the majority lack this knowledge. In this essay, I use a fictional case to trace the process for requesting access to an unapproved drug. I hope to explode several myths about the process, such as the notion that the FDA is the primary actor in granting access to unapproved drugs and the belief that physicians must spend 100 hours or more completing paperwork for pre-approval access.

Imagine you are a physician, and you have a pregnant patient who has tested positive for Zika. While she is only mildly ill, she’s terrified that her unborn child may be impacted by the virus, which has been provisionally linked with microcephaly and other abnormalities. She’s so concerned that she is contemplating an abortion, even though she and her husband have been trying to have a child and were overjoyed to learn she was pregnant.

Who Cares About the Doctor-Patient Relationship? A Review of “Next In Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”

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By KIP SULLIVAN, JD

A mere two decades ago, the headlines were filled with stories about the “HMO backlash.” HMOs (which in the popular media meant most insurance companies) were the subject of cartoons, the butt of jokes by comedians, and the target of numerous critical stories in the media. They were even the bad guys in some movies and novels. Some defenders of the insurance industry claimed the cause of the backlash was the negative publicity and doctors whispering falsehoods about managed care into the ears of their patients. That was nonsense. The industry had itself to blame.

The primary cause of the backlash was the heavy-handed use of utilization review in all its forms –prior, concurrent, and retrospective. There were other irritants, including limitations on choice of doctor and hospital, the occasional killing or injuring of patients by forcing them to seek treatment from in-network hospitals, and attempts by insurance companies to get doctors not to tell patients about all available treatments. But utilization review was far and away the most visible irritant.

The insurance industry understood this and, in the early 2000s, with the encouragement of the health policy establishment, rolled out an ostensibly kinder and gentler version of managed care, a version I and a few others call Managed Care 2.0. What distinguished Managed Care 2.0 from Managed Care 1.0 was less reliance on utilization review and greater reliance on methods of controlling doctors and hospitals that patients and reporters couldn’t see. “Pay for performance” was the first of these methods out of the chute. By 2004 the phrase had become so ubiquitous in the health policy literature it had its own acronym – P4P. By the late 2000s, the invisible “accountable care organization” and “medical home” had replaced the HMO as the entities that were expected to achieve what HMOs had failed to achieve, and “value-based payment” had supplanted “managed care” as the managed care movement’s favorite label for MC 2.0.