Thursday, January 24, 2019

Physicians

Physicians
The doctor is in ...

Médecins sans Hôpitaux (Doctors without Hospitals)

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There is lots of talk of disruption in healthcare particularly involving new entrants and weird combinations such as the CVS-Aetna merger, CIGNA and Express Scripts, Amazon Berkshire Hathaway and J.P. Morgan, and now Wal-Mart and Humana all claiming to transform healthcare. At the same time, we are seeing continued consolidation in the traditional healthcare industry with hospital systems merging at the local, regional and national level.

The rise of consumerism is affecting healthcare particularly the retail/primary care area where consumers are spending with their own money in a world of high-deductible healthcare.

The growth of digital health offers the opportunity to disrupt traditional care interactions in both the management of chronic conditions and in routine primary care. And there is a whole new set of patient decision-makers such as millennials who bringing with them different sensibilities in terms of access to services.

How I Learned to Stop Worrying and Love For-Profit Medicine

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flying cadeuciiWhen I started medical school, my South Asian immigrant parents quietly hoped I would find my way to cardiology or another glamorous specialty. Instead, I spent a decade — first as a medical student, then as an intern and resident in internal medicine — focused on advancing the right to health among poor people and others with little access to quality health care.

Through high-impact nonprofit organizations, political campaigns, and grassroots organizing in urban communities and among health professionals, I was part of an incredible community focused on making American medicine better, safer, and affordable to all.

So when it came time for me to find a “real job” after my residency, I assumed it would be in a nonprofit organization with a laser-like focus on transforming underserved health. Imagine my astonishment, then, to discover my life’s work in Iora Health — a private sector, venture-backed, for-profit primary care startup.

Profit and medicine

Critics have said that for-profit medicine makes money by finding ways to avoid caring for sick people “in their time of greatest need.” It’s also been pointed out that the Hippocratic oath doesn’t mention “money, financing, or making a profit.”

Information Blocking–The AHA Comments & PPR Responds

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The focus on the CMS rules on information blocking continues on THCB. We’ve heard from Adrian Gropper & Deborah Peel at Patients Privacy Rights, and from e-Patient Dave at SPM and Michael Millenson. Now Adrian Gropper summarizes — and in an linked article –notates on the American Hospital Association’s somewhat opposite perspective–Matthew Holt

It’s “all hands on deck” for hospitals as CMS ponders the definition and remedies for 21st Century Cures Act information blocking.

This annotated excerpt from the recent public comments on CMS–1694–P, Medicare Program; Hospital Inpatient Prospective Payment Systems…  analyzes the hospital strategy and exposes a campaign of FUD to derail HHS efforts toward a more patient-centered health records infrastructure.

Simply put, patient-directed health records sharing threatens the strategic manipulation of interoperability. When records are shared without patient consent under the HIPAA Treatment, Payment and Operations the hospital has almost total control.

PODCAST/PHYSICIANS/QUALITY: Interview with David Seligman, CEO of Best Doctors

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Here’s the transcript of the interview earlier this week with David Seligman, CEO of Best Doctors. Pretty interesting especially for those of you thinking about how to improve health care quality on a national and perhaps nationally branded level. (By the way, the transcriptionists at Castingwords are getting really quick! They only got this 36 hours ago). For those of you who prefer listening to reading the audio is here.

Matthew Holt:  This is Matthew Holt. I’m here with The Health Care Blog, and I’m talking with David Seligman. David is the CEO of Best Doctors, based in Boston, Massachusetts, and is also a locational contributor to the Boston Globe, as I noticed the other day‑‑and I’ve just found out, a regular reader of The Health Care Blog, which always is a pleasing thing.

David Seligman:  [laughs]

Matthew:  David, good morning. How are you?

David:  Good morning, absolutely, Matthew. I enjoyed being with you down at the World Health Care Congress, and I understand you’re going to be there again this year.

Matthew:  I’ll be looking forward to it. Anybody that’s listening can come by. I’ll be doing some blogging from there all three days.

David:  Excellent.

Matthew:  Let’s start with the real basics. I know that Best Doctors is a referral service and a second opinion service, and it’s obviously a lot more than that, but that’s, I believe, what it is at its core. For those readers of The Health Care Blog who are a bit more casual, can you just give the basic introduction to what you do, what problem you’re solving, and how you solve it?

David:  Yes, absolutely. Best Doctors is a global organization located with a presence in 30 countries around the world. It was originated by physicians from Harvard Medical School in the late 80s. What these physicians were seeing were many patients coming from around the US, and from other countries, to the Boston area, in search of the best information or the best medical care. They realized, back in the late 80s, that nine out of 10 of these patients could’ve, should’ve, stayed home with their local providers. Again, what they were looking for was what they thought would be access to better a quality of care and treatment. What we pioneered was a database of 50,000 of the world’s leading physicians in over 420 sub‑specialties of medicine. We tap into these physicians to really help us provide a comprehensive clinical review of serious or complex medical cases, and we really identify a correct diagnosis or course of treatment over 60 percent of the times in the cases that we’re doing, particularly here in the US. Once again, Best Doctors, we’re a global resource‑‑a trusted resource‑‑to help people with serious illnesses access the best medical care, without having to leave their local physician or local environment.

Academic Medicine Survival Guide

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The History of the Problem 

Martin SamuelsThe European University (e.g. Italy, Germany, France, England) descended from the Church. The academic hierarchy, reflected in the regalia, has its roots in organized religion.

The American University was a phenocopy of the European University, but the liberal arts college was a unique American contribution, wherein teaching was considered a legitimate academic pursuit.  Even the closest analogues in Europe (the colleges of Cambridge and Oxford) are not as purely an educational institution as the American liberal arts college.

The evolution of American medical education (adapted and updated from: Ludmerer KM. Time to Heal, Oxford University Press, Oxford, 1999) may be divided into five eras.

I.  The pre-Flexnerian era (1776- 1910) was entirely proprietary in nature. Virtually anyone with the resources could start a medical school.  There was no academic affiliations of medical school and no national standards.

II. The inter-war period (1910-1945) was characterized by an uneasy alliance between hospitals and universities.  Four major models emerged.  In the Johns Hopkins model, led by William Osler, the medical school and the hospital were married and teaching of medicine took place at the bedside. The Harvard model in which the hospitals grew up independently with only a loose alliance with the medical school, represented a hybrid between pre- and post-Flexnerian medical education.

Building Better Metrics: Invest in “Good” Primary Care and Get What You Pay For

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flying cadeuciiIn 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required.  These metrics ring as true today as they did many years ago.

Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients.  An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify.  A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access.  Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved.  Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”

“Remember that Oath?”: EPCS and the Fight Against Opioid Abuse

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By SEAN KELLY, MD

 

As doctors, we all took an oath when we graduated from medical school to “do no harm” to patients. It is, therefore, our duty to speak up and take action when there is an opportunity to prevent harm and improve patient care, safety and well-being. On average, the opioid crisis is killing more Americans on a monthly basis than traumatic injuries. It is time for the medical community to raise its voice even more loudly in support of proven technology that helps curb this crisis.

This month, California Governor Jerry Brown became the latest state lawmaker to embrace electronic prescribing for controlled substances (EPCS) — joining nearly a dozen other states that have passed legislation mandating that health care providers and pharmacies use the technology. The Golden State law was signed at the same time the U.S. Senate passed a bill requiring e-prescriptions for any reimbursement under Medicare Part D.

Clearly, EPCS is emerging as a key tool in the fight against opioid abuse. And legislators aren’t alone in driving the trend — corporations are playing a key role as well. Walmart, one of the nation’s largest pharmacy chains, is requiring EPCS by January 1, 2020. In their press release, it was noted that “E-prescriptions are proven to be less prone to errors, they cannot be altered or copied and are electronically trackable.”

Doctors and the Means of Production

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It was bound to happen.

By “it,” I mean that the small group of speciality hospitals (usually orthopedic or cardiology-focused) across that country that are owned by doctors were going to have their “See! We Told ‘ya so!” moment.

Doctor-owned hospitals: How many are there? Two hundred and thirty-eight of them in the whole country (out of more than five thousand)–somewhere between four and five percent of the total in the U.S. (numbers courtesy TA Henry from this excellent piece).

What are the issues?

  1. ObamaCare effectively bans doctors from owning hospitals in the U.S.
  2. Those already in existence are grandfathered in under the law.
  3. We know that doctor-owned hospitals have higher average costs–hence the rationale for banning them under a law with the intent of “bending the cost curve.”

Cue the iron-o-meter:

In the most recent Medicare data (December 2012 report on “value-based purchasing“), doctor-owned hospitals did well in terms of achieving quality milestones.

How well?

Really well. Physician-owned hospitals took nine out of the top ten spots in the country. And in spite of their low relative number, forty-eight out of the top one hundred.

The 5 Stages of EMR Acceptance (With Apologies to Kubler-Ross)

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                                                   DENIAL  

                 I can’t believe they are making me use this system!

                                                 ANGER

                I CAN’T BELIEVE THEY ARE MAKING ME USE WHAT 
                     THEY LAUGHINGLY CALL A SYSTEM!
                                                BARGAINING 

‘Look if I agree too willingly and cheerfully use this system, can you ask for and fund these change orders, add these features, re-engineer this screen…..blah! blah!  Blah!, etc. ‘
                                               DEPRESSION 

I can’t beeeelieeeeeeve (sob, sob, sob, sob) theeeey (sob, sob, sob) are making meeeee (pouring tears from both eye tear wells) use this system!’ 
                                             ACCEPTANCE 

           I believe they are making me use this system.
                                         (Resigned Sigh) 
And just as in the original Kubler-Ross model, our only release from EMR agony is death……. an eventuality that I used to accept stoically as inevitable, but now positively look  forward to its release (as do my carpal-ly tunneled wrists!). 

The Evolution of Precision Health

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Health 2.0 sat down with Linda Molnar to discuss the evolution of Precision Health, the imperatives at stake in a fast-paced field, and empowerment through big data. Linda has over 20 years in the field of Life Sciences and is responsible for a number of initiatives that further the field with start-ups, the feds, and for investors.

Her current endeavor is leading the upcoming Technology for Precision Health Summit in San Francisco alongside Health 2.0. “We’re never going to pull together all of this disparate data from disparate sources in a meaningful (i.e. clinically actionable) way, unless we talk about it” she says. “The Summit is an attempt to bring together the worlds of Precision Medicine and Digital Healthcare to realize the full potential of a predictive and proactive approach to maintaining health”.

Check out the full interview here.
As a bonus, save 25% off the standard admission to the Technology for Precision Health Summit by using discount code TPH25Register here!