It’s Telehealth Awareness Week! Today on Health in 2 Point 00, we cover Pager raising $70 million, bringing their total to $132.6 million. German-based company Ovivia gets $80 million, bringing their total to $127 million. Meru Health raises $38 million, and NOCD raises $33 million. —Matthew Holt
By HANS DUVEFELT
Perhaps it is because I love doctoring so much that I find some of the tools and tasks of my trade so tediously frustrating. I keep wishing the technology I work with wasn’t so painfully inept.
On my 2016 iPhone SE I can authorize a purchase, a download or a money transfer by placing my thumb on the home button.
In my EMR, when I get a message (also called “TASK” – ugh) from the surgical department that reads “patient is due for 5-year repeat colonoscopy and needs [insurance] referral”, things are a lot more complicated, WHICH THEY SHOULDN’T HAVE TO BE! For this routine task, I can’t just click a “yes” or “authorize” button (which I am absolutely sure is a trackable event in the innards of “logs” all EMRs have).
Instead, (as I often lament), I have to go through a slow and cumbersome process of creating a non-billable encounter, finding the diagnostic code for colon cancer screening, clicking on REFERRAL, then SURGEON – COLONOSCOPY, then freetexting “5 year colonoscopy recall”, then choosing where to send this “TASK”, namely the referral coordinator and , finally, getting back to the original request in order to respond “DONE”.Continue reading…
Recommendations From the Coalition for Physician Accountability’s UME-to-GME Review Committee: Winners & Losers Edition
By BRYAN CARMODY
If you’re involved in medical education or residency selection, you know we’ve got problems.
And starting a couple of years ago, the corporations that govern much of those processes decided to start having meetings to consider solutions to those problems. One meeting begat another, bigger meeting, until last year, in the wake of the decision to report USMLE Step 1 scores as pass/fail, the Coalition for Physician Accountability convened a special committee to take on the undergraduate-to-graduate medical education transition. That committee – called the UME-to-GME Review Committee or UGRC – completed their work and released their final recommendations yesterday.
This isn’t the first time I’ve covered the UGRC’s work: back in April, I tallied up the winners and losers from their preliminary recommendations.
And if you haven’t read that post, you should. Many of my original criticisms still stand (e.g, on the lack of medical student representation, or the structural configuration that effectively gave corporate members veto power), but here I’m gonna try to turn over new ground as we break down the final recommendations, Winners & Losers style.Continue reading…
By HANS DUVEFELT
Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.
Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.
The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.
An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.
He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.Continue reading…
By IAN MORRISON
I should’ve been in Paris last week on vacation with my wife, instead I listened in to the Policies Techies VCS: What’s Next For Healthcare conference (I’ll explain why later). Matthew Holt and Jessica DaMassa did a magnificent job of assembling the Who’s Who of digital health tech to wax lyrical about what the new kids on the block were up to, where it is all headed, and what it will mean for the system. (Full disclosure Matthew and Jess are friends of mine, I hired Matthew from Stanford almost 30 years ago to join the Institute For The Future (IFTF) and have watched proudly as he has become a Health 2.0 impresario. Jess simply deserves a gold medal for wrangling Holt and all the other tech Bros with wit, charm and intelligence).
This is a tumultuous time for digital health technology because of the pandemic and the related rise of digital solutions not to mention the very frothy investment market and massive deal flow over the last 24 months. There are a lot of exciting new faces. But, many of the companies on display have been at this for some. And for many of the old guard, like Livongo and now Transcarent Founder Glen Tullman, Athena Health and now Zus Founder Jonathan Bush, and Amwell CEO Roy Schoenberg and others this has been a much longer journey.
(Parenthetically, as a young management engineer in Canada, a position, I was not qualified for, I wrote the justification for an all-computerized hospital at the University of British Columbia in 1979! I still find it just incredibly pathetic that it has taken us 40 years to suddenly “discover” digital health. I wrote The Second Curve which forecast (among other things) the rise of digitally enabled health transformation 25 years ago! So it is hard for me to get really excited that this is either “new” or “next”.)
So, while a lot of us have been in this movie for a long time, there is something very different about the current crop of offerings. In particular, technology has advanced considerably and there are clearly new cloud and SaaS tech enabled care solutions. There is a new cadre of talented and committed investors and entrepreneurs who believe they have the capability and capital to scale meaningful enterprises that will disrupt incumbent healthcare players and better serve consumers and providers. And the timing seems right as the pandemic forced consumers and the health care system to confront new ways of doing business.Continue reading…
By RONALD DIXON
Week after week, I hear from colleagues in diverse specialties about how exhausted they are from practicing medicine.
It’s no surprise that they are looking for careers outside of medicine. The demands and strain are unsustainable.
So it’s also no surprise that a recent survey showed 40% of primary care clinicians are worried that their field won’t exist in five years and that 21% expect to leave primary care in three years as a result of COVID-19-related burnout.
While COVID-19 is the tipping point, this burnout is the result of the relentless and mounting administrative burden placed on us by electronic medical records (EMRs), coding and billing requirements and prior authorizations. And then it is exacerbated by uncertainty mounting in the primary care field, with new medical care entrants popping up everywhere — from retail pharmacies to digital health startups — aiming to create their own primary care model, replacing rather than working with existing ones.
Where it All Began
The roots of this burden began three decades ago with the advent of an acronym that few outside of the healthcare world know of today — the resource-based relative value scale (RBRVS). This payment system, launched in 1989 and subsequently adopted by Medicare in 1992, led to what we know now as the foundation of the U.S. healthcare payment system.
The RBRVS system assigns procedures a relative value which is adjusted by geographic region. Prices are based on physician work (54%), practice expense (41%) and malpractice expense (5%).
Since the initiation of the scale, the relative value of specialist work has remained much higher than primary care. This disparate compensation, in combination with most health maintenance and patient supportive tasks delegated to primary care, has led to significant fatigue.Continue reading…
By HANS DUVEFELT
Especially in these strange and uncertain times, many people feel uneasy. Some of them come to us with concerns over their state of mind.
In primary care, our job is in large part to perform triage. We strive to identify patients who need referral, medication or further evaluation. We also strive, or at last should strive, to reassure those patients whose reactions are normal, considering their circumstances.
A set of emotions we consider normal during the first weeks of the loss of a loved one may constitute pathology of protracted or if there is no apparent trigger.
But what is normal in today’s reality?
People today often have a low tolerance for deviations from the mean. They measure their heart rates, sleep times, steps taken, calories eaten and many other things on their smartphones. They compare their statistics to others’ or to their own from different circumstances.
Is it normal to sleep less when the last thing you do before bed is take in the latest disaster news? Is it normal to have a higher resting heart rate when you are threatened by eviction? Is it normal to feel sadness that life as we knew it doesn’t seem to be within our reach right now?
The worst thing we can do is tell people there is something wrong with them if we see them doing and hear them expressing what many other people also do.
It’s bad enough to feel bad, but even worse if you think your reaction is a sign of psychiatric illness or psychological or constitutional inferiority.Continue reading…
By KIM BELLARD
In a week where we’ve seen the bungled Afghan withdrawal, had Texas show us its contempt for all sorts of rights, watched wildfires ravage the west and Ida wreak havoc on a third of the country, and, of course, witnessed COVID-19 continue its resurgence, I managed to find an article that depressed me further. Thank you, Aaron Carroll.
Dr. Carroll – pediatrician, long-time contributor to The New York Times, and now Chief Health Officer of I.U. Health — wrote a startling piece in The Atlantic: We’ve Never Protected the Vulnerable. He looks at the resistance to public health measures like masking and wonders: why is anyone surprised?
Some of his pithier observations:
- “Much of the public is refusing. That’s not new, though. In America, it’s always been like this.”
- “COVID-19 has exposed these gaps in our public solidarity, not caused them.”
- “America has never cared enough. People just didn’t notice before.”
Wow. What was that about Texas again?
Some of Dr. Carroll’s examples include our normally lackadaisical approach to influenza, our failure to recognize the dangers we often pose to immunocompromised people, our paltry family and sick leave policies, and our vast unpaid care economy. He could have just as well pointed to our (purposefully) broken unemployment system or the stubborn resistance to Medicaid expansion in 12 states (Texas again!), but you probably get the point.
Everyone likes to complain about our healthcare system – and with good reason – but it is not an abyss we somehow stumbled into. It’s a hole we’ve dug for ourselves, over time. We may not like our healthcare system but it is the system we’ve created, or, perhaps, allowed.
Health insurance was once largely community-rated, spreading the risk equally across everyone to protect the burden on the sickest, until some insurers (and some groups) figured out that premiums could be cheaper without it. Use of preexisting conditions and medical underwriting also served to protect the less vulnerable, until ACA outlawed those practices.Continue reading…
By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER
“Why did you choose this field?” Most physicians are asked this question at some point in their early careers. We are geriatrics and palliative medicine physicians, so when that question is posed to us, it is invariably followed by another: “Isn’t your job depressing?”
No, our job is not depressing. We are trained in the care of older adults and those with serious illness, and we find this work very rewarding. What truly depresses us is how many vulnerable patients died during the pandemic, and how the scourge of COVID-19 revealed the cracks in our health system. Never before in modern times have so many people been affected by serious illness at the same time, nor have so many suffered from the challenges of our dysfunctional health system. Our nation has now witnessed the medical system’s failure to take comprehensive care of its sickest patients. This is something those in our own field observed long before the pandemic and have been striving to improve.
All of us practicing geriatrics and palliative care have had a loved one who has been challenged by aging, by serious illness, or indeed by the very healthcare system that is supposed to help them. As medical students and residents, we personally confronted these systemic deficiencies and wondered about alternatives for those patients with the most complex needs. We chose fellowships in geriatrics and palliative medicine because we wanted to try and make a difference in the healthcare that is offered to our most vulnerable patients.
During the New York City surge in the spring of 2020, we were front line workers at a major academic medical center. While the global pandemic took us all by surprise, our clinical training and passion for treating vulnerable populations left us feeling capable and ready to serve. Due to the urgent needs of overwhelming numbers of extremely sick patients, our Department was charged with rapidly expanding access to geriatrics and palliative care across our seven hospitals. We were embedded in Emergency Departments (EDs), hospitalist services, and critical care units. We roamed the hospitals with electronic tablets and held the hands of dying patients, while urgently contacting families to clarify goals of care. For those who wanted to receive care in the community, we scrambled to set up telehealth visits and coordinate the necessary support. Way too often we could not meet their needs with adequate services, forcing them to visit overwhelmed Emergency Rooms.
While we helped individual patients and eased some of the strain on our hospitals, our system was overwhelmed and mortality numbers continued to steadily rise. Within our hospitals, staff were redeployed to care for the most critically ill in the emergency departments and intensive care units. In this frantic time, we were fortunate that our hospitals had sufficient medical resources to care for the sickest patients and for the staff. However, the sub-acute nursing facilities (SNF) and long-term care facilities strained to protect their residents and their employees. Shortages of PPE, staff, space, testing supplies, and funding all contributed to the high mortality numbers we saw in many NYC facilities and across the nation. There were also limited resources allocated to delivering outpatient care in our patients living in the community. The rapid shift to telehealth was not feasible for many of our older patients, and even when it was possible, the delivery of diagnostic and therapeutic care was limited and suboptimal.
Data now shows that older adults and those with underlying chronic illnesses were disproportionately affected by the COVID-19 pandemic, experiencing higher hospitalization rates as well as higher death rates. Although adults 65 and older account for only 16% of the US population, they represent 80% of COVID-19 deaths. Residents of nursing homes, the frail homebound, and older people of color were the hit the hardest. Thirty-five percent of the deaths in the US from March-May 2020 occurred among nursing home residents and employees. Nationally, over 600,000 nursing home residents were infected with COVID-19 and over 100,000 died from the disease. These data are underestimates and the death toll is likely higher. We cannot explain why older Black Americans were 1.2 times more likely to die than white Americans nor why the odds of dying from COVID were nearly two times higher for persons living in South Dakota as compared to Wyoming or Nebraska. Often, the paid caregivers for these vulnerable patients were themselves vulnerable underpaid women of color who were at higher risk of contracting COVID.Continue reading…
By HANS DUVEFELT
I am a 68 year old family physician in rural Maine. This morning I read yet another article about physician burnout, this time in The New York Times. (I’m not linking to it, because they have a “paywall”.)
I did not end up exactly where and how I expected to be at the end of my career, or life in general to be brutally honest. But I am the happiest I have been since the beginning of my journey in medicine.
I have a balance in my life I didn’t have, or even seek, for many years as I juggled patient care, administration, raising a family and pursuing interests that often brought me away from home.
My days in the clinic are a bit shorter than they used to be, but in the past several years I have had to do much more work from home – even more so in the last two. The “half-empty glass” way to look at this is that work has intruded more into my personal life and my home. The “half-full” view is that I can do my computer work when it suits me the best. For one of my clinic positions, I can do charting on an iPad mini in bed, coffe on my nightstand and sleeping dogs at my feet. The clumsier EMR requires a laptop (which in my view can’t be used the way its name might suggest) I sometimes work on in the barn and sometimes on a picnic table in the grass outside.
Ironically, the pandemic has brought me a peace and clarity I probably wouldn’t have achieved otherwise.
I had thought moving back to Caribou for a position with no administrative responsibilities would open up social opportunities I hadn’t allowed myself for the last few years. I expected to become involved with the Swedish community here, connecting more with neighbors and other horse owners, and so on.
But the lockdown forced me to sit more with my own thoughts, my own feelings and memories. It forced me to consider, not for the first time but again, that in this unpredictable life, the only sure thing is that I am me and I am where I am.Continue reading…