Friday, July 20, 2018

Physicians

Physicians
The doctor is in ...

Practicing Physicians and Healthcare Reform: Population Health vs. Compensation Wealth

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In her August 14th 2016 interview with the LA Times regarding the ACA and value-based reimbursement, HHS Secretary Sylvia Burwell stated, …”and medical providers want this.1” After reading this article, I wondered for a moment if I am working in the same healthcare system as the Secretary.   Having spent a significant part of my 36-year career negotiating financial transactions with and/or on behalf of practicing physicians, I can unequivocally state that, unlike healthcare thought -leaders and policy wonks, a scant few practicing physicians are on board with population health management, value-based care and the “triple aim.”

It is essential to significantly improve the value of healthcare and it will require a lot of work by all.  Given the disconnect between the policy makers/‘thought- leaders’ and the nation’s practicing physicians, I am pretty sure we are not going to get very far.   Most practicing physicians consider the current movement to value based care/population health to be ineffective, expensive, bureaucratic interference with the practice of medicine.

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.”

How to Build Better Metrics: Focus on Physician Outcomes

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flying cadeuciiQuality measures began as tools to quantify the healthcare process, using outcomes, patient perceptions, and organizational structures associated with the provision of high-quality health care. Overall, the goals should focus on delivery of care that is effective, safe, efficient, and equitable.  Did you notice a particular word missing?  Yes, I missed the word physician too, because they have been left out of the conversation entirely.

Measuring quality healthcare by a patient lab result is like recording a patient’s temperature by waving the thermometer near their face.  One has little to do with the other except for the slight appearance of connection.  Quality must be measured by physician outcomes and not those of patients.  For instance, our county does not have fluorinated water.  Measuring the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care provided.  A physician outcome would be calculating the percentage of children who received a prescription for supplemental fluoride during their office visit.

If the intended goal is to reduce unnecessary ER visits, then we must determine the root cause.  Patients with private insurance rarely go to the ER for non-emergencies because they pay a large out-of-pocket cost.

Dear Mr. Slavitt, Please Come Visit My Office

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flying cadeucii

Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.

Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?

Focusing on Primary Care for Better Health

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Screen Shot 2016-07-07 at 2.30.28 PMIn the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.

The road to a better health care system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care.

An Alternative Proposal For Certification

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John HalamkaSome have suggested that my comments over the past few months about the Meaningful Use program, MACRA/MIPS, and Certification imply that we should just give up – throw out the baby with the bath water.

That’s not what I’ve written.

Here’s a clarification.

I believe MACRA/MIPS is the right trajectory – create a set of desirable policy outcomes, then enable clinicians to choose technology, quality measures, and process improvements that are relevant to their practice.

Although the current MACRA formula is overly complex, it’s the right idea and I’m confident that CMS will revise the notice of proposed rulemaking appropriately.   My metric for MACRA’s success is simple – can a clinician keep three goals in mind while seeing a patient and be rewarded if successful i.e.:

1. Ensure care is delivered in the most appropriate location in the community (urgent care, home care, rural hospital)

2. Focus on wellness/prevention

3. Avoid redundant and unnecessary testing, medications, and procedures

My issue is that MACRA currently “inherits” the flawed 2015 Certification Rule that is a kitchen sink of immature standards and a black hole for developers.   Overly zealous regulatory ambition resulted in a Rule that has basically stopped industry innovation for 24-36 months since it has listed every use case for every purpose including those unrelated to Meaningful Use and MACRA.

Why Medicine?

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By SAURABH JHA, MD

flying cadeuciiCross posted with Quartz.

When I was applying to med school some 20 years ago in the UK, I was advised not to say at the interview: “I want to be a doctor because I want to help people.”

The answer was considered too dull back then. And in any case, I was asked “Why medicine?” only once.

“I’m not sure, but it’s not because my parents forced me.” I hesitatingly answered.

The interview panel giggled at my honesty, and for breaking a stereotype about Indians. I was accepted. But I doubt that this answer would cut it today.

Showing a sense of altruism is practically mandatory today for would-be doctors – one wonders if functional MRI will soon be used to prove empathy. But when I was 17 (the age when we typically applied to study medicine) that wasn’t the case. My curriculum vitae had little evidence that I wanted to help people.

The Angry Physician

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I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy.  Medicine is a calling, and I treated it as such.  I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals –  they would take care of the task of taking out the bad elements of our healthcare system and leaving the good.  I truly believed.  I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.

It took me two years to realize the meaninglessness of meaningful use.  I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope.  I thought – this was a first draft, improvements would come.  What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down.  There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march.  Except the road would no longer be paved and we would be walking uphill.

Don Quixote and the Health Professional’s Endless Quest

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April 22 marks the 400th anniversary of the death of the greatest novelist who ever lived, Miguel de Cervantes. Though the day will pace unnoticed by most physicians, it is in fact one many should note. Why? Because both his life and work can serve as vital sources of inspiration and resilience for health professionals everywhere.

In a 2002 Nobel Institute survey, 100 of the world’s most highly regarded writers named his Don Quixote the greatest novel of all time, outscoring its nearest rivals –works by Dickens, Tolstoy, and Joyce – by more than 50%. Said the head judge who announced the results, “If there is one novel you should read before you die, it is Don Quixote.”

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.